Laserfiche WebLink
SAN .10AQUIN COUNTY **Aloe opiGNAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> �..- �;;�• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> uFaa <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,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 290!5W Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN 097-600-03 <br /> Property Saratoga, <br /> Owner Leonard E.&Pauline Borello Address 14004 Quito RoadCity/State CA Zip 95070 Phone <br /> C-57 Contractor 6rj/j�)ji1)' _ Address 151) 1,iQ City/StateM _LicY85J(o�_Phonq'l>Ui) 313'5Boo <br /> Consultant/Sub Cntr tantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 <br /> Billable Party(consuitantServices, Inc. Address City/State Cordova,CA Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(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(i.e.Air Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> 1 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:Mw-10 ( (�M <br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines PRESSURE GROUT(see well Destruction Details Table) <br /> EXPLOSIVES FROM TO FT BELOW SURF <br /> TREMIE TYPE TO BE USED:❑AUGERS ElHOSE 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 I applicable California laws. <br /> Signed Title/Company Senior Geologistii Stantec <br /> Print Name Shane Olton Date fJTlola 13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED B DAT PIF A <br /> GROUT INSPECTION BY —s FINAL INSPECTION B GATE 1' -/ <br /> DESTRUCTION INSPECTION BY DATE 3-13—/ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> SREQUEST <br /> PR# <br /> $125. / DO 39eP19J <br /> '350-0 � 33 � 00 <br /> [] PR# <br /> s90 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC !/ <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />