Laserfiche WebLink
• • FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • •- �;'P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehR� �� <br /> ql/FOR � �m1�1. JJIL� � �,I�/ <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIOIAPR 14 2014 <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 mE" bl?TAIbKEALTH <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmentPERMIT/SERVICES <br /> Site Location 1634 S Stockton Street Cross Street West 3rd Street City/State Stockton Zip 95206 APN <br /> Property <br /> Owner City of Stockton Address 425 E1 Dorado St. City/State Stockton Zip 95202 Phone 209-937-8366 <br /> C-57 Contractor <br /> National EWP Address City/State Lic Phone 1961 Meeker Avenue Richmond 953646 510-236-6282 <br /> Consultant/Sub Cntr Geosyntec Address 3043 Gold Canal Dr, #201 City/State Cordova—Lic Phone 916-637-8333 <br /> Billable Party John Taylor Fertilizer Address PO Box 1030 City/State Marysville Zip 95901 Phone 530-742-2539 <br /> GIS Coordinates:X -121.299817" Y 37.934089' <br /> 32 or 34/0 -/2(,124'FP <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW EL ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> M WELL IDs MW-12 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 X❑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 [D PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEALapprox. 75 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(i a Air Soaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ®OTHER:Sonic APPROX.BORING DEPTH approx. 90 feet ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No®Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 W ELL(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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable California laws. <br /> Signed Title/Company <br /> �� Hydrologist, Geosyntec Consultants <br /> f <br /> Print Name <br /> Grant Hurst Date 4/10/2014 <br /> bb <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS U /q Jr S <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J Yo)9,x r✓l DATE ISS V `w���`�. '/y AREA /G <br /> ---------- -- <br /> GROUT INSPECTION BY FINAL INSPECTION BY Q� '"'l DATE <br /> - <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 /> Z�U� $125x / SR# <br /> RO# <br /> ZC(O 75 (3500) <br /> PR# <br /> (2900 <br /> C-57 f/ WC Ir WAIVER )4/ k�--C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />