SR2601932 - Laserfiche WebLink

Home Browse Search

`�� S A N 10 A Q U I N Environmental Health Department C,�l1�P�'"fJ ��nrtf-net rerr,g5 �nr SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL. IQW, 953-•7697 for INSPECTIONS 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 Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address /0 y jj 5. L ;j S,W i `y c 4 Clty/State1ZipSj0(,((I'0!) Cp, 5��Phone Cross Street L A►Vg-%Q 5,oA --5t, APN yb,?, Property Owner" I S „ e Phone Address d� 5. U3:C-"Nyl Vj City/State/Zip o OC*ft{ 4 � C-57 Contractor ��A_��C,. License# 6,, Sj 40 Phone:!Uo- L- ql- a2-' 3 Address 3-1� Tc'-� f" City/State/Zip AAol6 s Cf4, $'bC>1 Consultant/Sub-ContractorAl�1iWMkAaj 1(- J:CQ) License# ,5-4 (,. Phone'530-9D�-L) ((o Address 6,6,o AIGt✓tzj A; ,-4 , Ct S,lAe- r, City/State/Zip cthrLp rA �lS�aC- CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Cl MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER O SOIL BORINGS ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Ar Soaroe Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER 2 I 2 OTHER: _ GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) PiELU SOIL BORING Cs �2T GROUT SPECIFICATIONS 4,41iil�—jJW�<h.' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) '/WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feel WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TRENIIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. C_ Signed QC j,—"'f ,(,,—k Title/Company 1'�;i(,yrjef 94 . ✓tUi fc�lllMP n�-G� d�,�f);C�f Print Name j�j!n/yy1 r'��' 1�L-l �� _Date 3- 3 62-L. DEPARTMENT USE ONLY Application Accepted By: f Date Issued: 3 ZX� Grout Inspection By,'Dates: l Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C•57 ❑C•57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waive; ❑Encroachment Permit [:]Access Agreement ead Agency Approval 19 MFR COMMENTS/CONDITIONS: WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit (&'j $179 x y -(� f '�� 540 1868 E. Hazelton Avenue I Stockton, California 95205 I T/ 2na AF- - P 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 L L(�f j(6 j 0`iJ Site Mitigation Well Permit Application