Laserfiche WebLink
SAN JOAQUIN COUNTY -LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION <br /> UNIT IV <br /> 1110 t 600 East Main Street, Stockton,CA 95202-3029 ---. <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NOW. <br /> 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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Between 1760 & 1802 South ✓irgoaaut St Charter Way Cny Stockton Zip 95206 APN <br /> Site Location Cross Street <br /> Property 425 El Dorado St. Stockton 95202 209-937-8366 <br /> PropOwner t:ity of Stockton Address <br /> City Zip Phone <br /> P kAdrenS City is 777-007 <br /> Gn robe tinvironmental P es p0 Box 6093 Oroville LIC Phone 530-589-2019 <br /> C-57 Contractor <br /> Consultant/Sub Cntr Geosyntec Address _ 475 19th St., Ste 400 City Oakland LIC Phone 510-285-2700 <br /> Marysville 95901 530-742-2539 <br /> Billable Party John Taylor Fertilizer Address ro Box 1030 City Zip Phone—_,__ — <br /> GIS Coordinates'X -121.304941 Y 37.931683 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,!GEOPROBE HYDROPUNCH,HAND AUGER,OTHER) <br /> ®SOIL BORING 10s - SG-1 and SG-2 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 171 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 /> J❑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(1(3 AirSUarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS_ I nNeArT <br /> Temporary Soil BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> 2 ®OTHER: vapor probe MOTHER:Geoprobe 2" dia.APPROX.BORING DEPTH ❑ <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS:samolc port.u,wi.II Lu removed same day t borings backfilled with <br /> �,�ri+re CiLy lincroachment Permit attachod <br /> NOTE: OFFSITE WELLS S R BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATAPPLY) <br /> #OF WFt I(S)TO BE DGSTROYEO ❑OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> ❑PRESSURE GROUT TO DEPTH 01: FT BELOW SURFACE <br /> WELL IDs: ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[]AUGERS HOSE PIPE ❑ <br /> COMMENTS <br /> 5 WORK;gj. 0T <br /> TICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that hi ap leation and thatthe work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and allr I s. Staff Engineer, Geosyntec Consultants <br /> Signed Tttle/Companyreea Kullit <br /> en DOtg pa i! "Vy <br /> Print Name - - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE1 ADDRESS IE; S <br /> WORK PLAN DATED—71- t L t - <br /> _ _— DATE ISSUED t c1 �,L__.AREA <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY -(A • s ram 2 1% �/ FINAL INSPECTION BY, 1 -A �- DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS- <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK f RECV D BY DATE REQUEST PR# _ <br /> Z°1v5 <br /> $1szX IZ2_,vo z cl I► sR# 093`1-- <br /> RO# <br /> Zgv3 -3b6,O (31f00) <br /> --- <br /> iso#015c�563�(3 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ^ENCROACHMENWEtDOC <br /> APP <br /> EHD 20-01 07/28110 <br />