WORK PLANS - Laserfiche WebLink

Home Browse Search

S AN ��QA Q Environmental Health Department -COUNTY-Greatness Crows her Cir:�pJ: SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 521 (North Cherokee Lane lr 26j,�) CttylStatelZlp Lodi, CA 95240 Phone (209) 601-6694 Cross Street Murray street APN y N1yreF',4, sT"Rf�T Clt' �•� G«�l Property Owner" f1AZA" `i+1 if . Phone (2C9) 553-6937 Address ad /t1LA"y S;Y'QE�j t CA a-1220-- I ys-.z y U C57 Contractor I a"P-1 6-eQ LicenselF /43?19r9- Phone lb _ 77 60f q Address 7 q SVh)R 5E— e-I S% r e 8 33 eitylStatelZip IQo.S c-y1Ite 4 e4 95V79' Consultant/Sub-Contractor Stephen G. Muir consulting Geologist License# CEG 1224 phone (209) 369-9421 Address PO Box 152 CitylStatelZip Woodbridge, CA 95258 CONSTRUCTION WORK TO BE PERFORMED:*Note: Ofrsite BoringsMells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING �❑ HOLLOW STEM BORING DEPTH BOLTEDTRAFFIC BOX Cl STOVE PIPE EXTRACTION(Vapor/Water) ❑ HAMMEWDRIVEN DIA.OF BOREHOLE /�-,,�❑MULTIPLE CASINGS[IMULTI-LEVEL WELL CASING DIA El SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS S'CS1 f y TYPE OF CASING: ❑STEEL;&PVC ❑ OTHER ❑ SOIL BORNG ❑ PUSH POMT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia:10" Casing Dia: _-2-!! Casing Depth: ❑ INJECTION{AirSnarae.ozonel ❑ HAND AUGER GROUT SEAL DEPTH ;;Z.-.-q'] S TREMIE TYPE TO BE USED:*UGER5 ❑HOSE ❑PIPE s,V1-t')•&jyt� ❑ OTHER _❑ OTHER: GROUT SEAL PUMPEO7 ❑Yes o (Nate:Maximum Ereefa3l Depth is 30 Ft) PtC lwr� /'e, WEW SOIL BORING Ins -' GROUTSPECIRCATIONS 9-s k mix or as directed by .9JCEHD inspector. 5 r47r�c H E1� AA&j!."b 1voll CD DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL;rHgTAPPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs [:]PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS HOSE ©PIPE ❑MUSHROOM CAP 1]3 feet below surface or feet below surface if>3 feet COMMENTS: -'e <e,( L( " ;-')C--,r,I-A 4- PA Ckcclv't- I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Sa Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed 1, Title/Company SfifePhen G. Muir Consulting Geologist Print Name Stephen Muir Date +n � DEPARTMENT USE ONLY �i Application Accepted By: t { �i r'.'}•'Ls� Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit Site Information FA Name �.t t� -L} CSC FAAddress A), C"' rob FA�t � � � PR# 0 5 �} FA PE C WP Reviewed By I Work Plan Date ❑C-57 G57 Authorization for Other to Sign Permit ❑Workers Camp ❑Workers Comr mr er ❑Encroachment Permit ❑Acc2�s,Agreement P ead Agency Approval MFR COMMENTS( NDITIONS: h 4't1 C Ct.C.l I m" ("tt+t. �0 C ob 4 b� - I?'ter �, k�_ f� t r i;t. i«h��l 4 . WP TYPE PE SC FE INFOj AMT REMITTED CHECK# RECV'D BY A WE�LtL PERMIT i f/_ INVOICE# Permit -q0 s,� 1 x + + :41 lr / -41 1868 F- Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 ww .sjce d.co{m EHD 25-01 04-20-23 Site Mitigation Well Permit Application