Laserfiche WebLink
0¢4`'1'•. SAN JOA UIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.ora/ehd <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />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. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1y1115-.31 and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location / ? 710 6- / e Cros Street City/State '16);V1 Zip ®5'Z SAO APN Otic S <br />Property y /� r d� i!f'✓E <br />Owner Si9^�JORQu/� Adddress /� uU %��� <br />/ �� City/St f Zip Phon <br />C-57 Contractor 6* elFa AW/«�"YAddress SV ~F /4 Cit�/State "QO2 e� Phone , <br />Consultant/Sub Cntr �8 T Ad�d/r''e'syys ��a�� � Ry/State 56�WLicLfff� % Phone 9,-S---�� <br />Billable Party S'gi✓ ✓yA cru/�✓ �"�1�dd�erss—d�/!'�A u' �� City/State Sr�;�Zip-44r"/ Phone�g <br />GIS Coordinates: X 3-P D -0:z Y <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />❑ SOIL BORING IDs <br />WELL IDs <br />❑ OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 6,S'C •1dRC f't-*A <br />MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 6�MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: <br />_E1EXTRACTION: Vapor/ Water [IHAMMER/DRIVEN CASING THICKNESS fro TYPE OF CASING: ❑ STEEL�XPVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE F MUD ROTARY DEPTH OF GROUT SEAL Z-95 REMIE TYPE TO BE USED: AUGERS XHOSE ❑ PIPE <br />_❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />_❑ INJECTION (i.e.AirSparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS O / 097 G���✓/ <br />_❑ OTHER: OTHER: AIR ROT&APPROX. BORING DEPTH S / S �%❑ BOLTED TRAFFIC BOX OR STOVE PIPE <br />i /EL` CONDUCTOR CASING EJ No ❑ Yes: Casin Dia: Casing Depth: Boring Dia: <br />COMMENTS: !'� LllL.4�E© y✓ES/ Slit Cr /7-W ��t��G <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># OF WELL(S) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I have p r d this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all app li lifornia laws. // _ <br />Title/Company S/I/ t/&WQt�C//✓ <br />Signed ,z <br />Print Name <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED` % 2y <br />DEPARTMENT USE ONLY <br />—/0li•/%1—SC/Z/!, <br />APPLICATION ACCEPTED BY <br />9 v �i79 L. %� SiG/3 /3 7 i'J1il d 1y� DATE ISSUED `� AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY �T��+ DATE fISV4 <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: &�- mar h-� ee !O !�• / � - .," CG"� 4--�-Ac 2 - <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE SERVICE <br />REQUEST <br />I RO # <br />PR# <br />INVOICE <br />J7IgW <br />$125x6-71/7 <br />SR# <br />0 J 0 /,o <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 5/09/12 WELL PERMIT APP <br />