Laserfiche WebLink
Address tc-c-Ka &*coS BLVD. <br />Job Address }40 7, ChAN1,41 ft, LA/0 • <br />Phone 1"/Pr Property Owner* $A 9.. • •4 $ VOA N6-5 <br />ments or Encroachment Permits e: Offsite BoringsNVells Require Access Ag CONSTRUCTION WORK TO BE PERFORMED: <br />CASING THICKNES <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CON <br />MONITORING El HOLLOW STEM <br />EXTRACTION (Vapor/Water) CI HAMMER/DRIVEN <br />CI SOIL VAPOR PROBE 0 MUD ROTARY <br />0 SOIL BORING 0 PUSH POINT (GP/ CPT) <br />CI INJECTION (Air Soarqe, Ozone) 01 HAND AUGER <br />CI OTHER 0 OTHER: <br />WELU SOIL BORING IDs -w , 1143.v S1S,frtW <br />tAAA.i•-• r9 <br />sz) ' IX Yes U o Boring Dia: 1/ Casing Die: /0 " Casing Depth: <br />TREMIE TYPE TO BE USED: C1 AUGERS 0 HOSE 0 PIPE <br />131 No (Note: Maximum Freefall Depth is 30 Ft) <br />P611-- G-tA k 0 nre3 <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: / <br />Destruction Inspection By/Dates: <br />ion <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards <br />RECEIVED <br />JUN 2? 2017 <br />ENVIRONMENTAL HEALTH pERMIT/SERVICES <br />Cross Street Fla11A6LAI-i AVO. • <br />City/State/Zip •71-t)(4/.--T-1FVsi t CIA etrik IPhone <br />APN <br />TED TRAFFIC BOX 1:1 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL Eir'PVC 01 OTHER <br />GROUT SEAL PUMPED? ID <br />GROUT SPECIFICATIONS <br />BORING D H qr.) c4- t31S <br />DIA. OF BORE a E s " <br />ICH *0 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS CI HOSE El PIPE <br />DESTRUCTION M <br />El OVER-BORE <br />CI PRESSURE GROUT <br />CI EXPLOSIVES <br />El MUSHROOM CAP <br />OD: (CHECK ALL THAT APPLY) <br />METER of inches to depth of feet <br />To d- , of feet below surface <br />From to feet below surface <br />El 3 feet be surface or feet below surface if >3 feet <br />I hereby certify that I am autho <br />San Joaquin Coun <br />Signed <br />Print Name <br />ed to complete this application and that the work will be done <br />Ordinance Codes and Standards, and all other applicable Californ <br /> Title/Company <br />Date <br />accordance with <br />laws. <br />DEPARTMENT USE ONLY <br />FA Name <br />,- <br />rc, iv'.-A' c-A^tAi r 6 i"` (4-6•J1/41" 1 <br />"lt(4-to Si <br />FA Address ,:Y t 4 .1 C4) <br />0 wA <br />FA# 002-'--1 1 g'3 PR# 0 c-t4 0 -7 <br />FA PE v2 cl STh WP Reviewed By L —N' Work Plan Date t 0 / (a I <br />E1(57 0 0-57 Authorization for Other to Sign Permit arrNorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 11 Access Agreement EK:ead Agency Approval [Er<FR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit I__ 1 c i 3 1 :.. il.lifx 4\ -( 21 SLIO) <br />COMMENTS: <br />Address <br />Address i 4t(I City/State/Zip ILLCA44A0NO, NS- '9 (-CI 04 <br />Consultant/Sub-Contractor Srprocv License# Phone <br />C-57 Contractor Cpscp-e iNar- <br />LA 42- • City/State/Zip CrOLfr--TDIN, OA- 2.0 ol <br />License# n Phone 530 • - 2-1( 2- `7 <br />City/State/Zip t,OS (9-gym <br />UCTION SPECIFICATIONS