Laserfiche WebLink
Pa''i"�• SAN JOAQUIN COUNTY <br /> Y 'y ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ,•� . 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV <br /> C�4,•. :::•a�P Telephone:(209)468-3454 Fax:(209)468-3433 Web:WWW.sigoV.org/ehd <br /> �/FOR <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, <br /> �/Chapter 9-1115.3,and the <br /> }Standards of the San Joaquin County Environmental Health Department. 175-/70_ <br /> Site Location � �tPiF/t/Cts- Cross Street t/O"(fjj A'W- City Zip 1 s ib APN /7j IID-0JIO� / <br /> Property � Q <br /> Owner Address-VokaatAaL���&City SZip 70 <br /> Phone B/7"�� =0 <br /> 1 -5S"7 <br /> C-57 Contractor Yrs f511T�� Address 23�,5 WgWiNt� City Lic 63(0301 Phone 2,0q'7�ro !let <br /> Consultant/Sub Cntr Address';N7O--/<5v' �city Lic Phone 111b 4?79 x•313 <br /> Billable Party kl's -- — Address cS -h't�� Lcr1 City Zip Phone <br /> GIS Coordinates:X 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 <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fi.e.AirSoaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> p��� / c CONDUCTOR CASING❑N ❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: �� /Ml lT .r� � /� we!/ <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: W- h MW.-3 0 PRESSURE GROUT TO DEPTH OF 25^32- FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 1 Rfid 3'� i�G EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS ❑HOSE ❑PIPE MUSHROOM CAP AT(?3 FT) 2-'4 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Ruwlels1 <br /> Regulations,and all applicable California Laws. P'{o Q <br /> Signed Title/Company Q GC.E-ve <br /> Print Name Date _ <br /> DEPARTMENT USE ONLY `Gc <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> O EtaoMEN <br /> WORK PLAN DATED ,�2r0 <br /> APPLICATION ACCEPTED BY DATE ISSUED �L/��Cr AREA <br /> GROUT INSPECTION BYo�c+,� �`" FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR,#/ <br /> 'YS/7,2— $125 x �v SR# 101016 q <br /> Ro# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />