Laserfiche WebLink
RECEIVED RECEIVED <br /> > Pg FEB 17 2016 SAN JOAQUIN COUNTY DEC 03 <br /> INVIRONMENTAL HEALTH DEPARTMENT 2015 <br /> ENVIRONMEN <br /> "- <br /> EALTH DEPARTMEW Hazelton Avenue, Stockton, CA 95205-6232 EtVV'r'0NME <br /> c Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sicehd.com PCRMrr/ERVIC SL�N <br /> SITE MITIGATION 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. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 110 West Beverly Place City/State/Zip Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-153-12 <br /> Property Owner" Mark Church Phone 209-814-2493 <br /> Address PO Box 121 City/statatzip Tracy, CA 95378 <br /> C-57 Contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/State/zip Sacramento, CA 95826 <br /> Consultant/Sub-Contractor Advanced GeoEnvlronmental„Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/Stateop Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require.Access Agreements.or Encroachment Permits <br /> TYPE OFWELUBORINGUN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING OEM ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXFRACTION(Vapx1Water) ❑ HAAW£RNRVEN DIA OFBOREHOLE ❑MULTIPLE CASINGS MULTH.EVEL WELL CASING DIA <br /> ❑ SOLVAPORPROBE ❑ MAID ROTARY CASING THICKNESS TYPE OF CASING: 13 STEEL 0PVC 0 OTHER <br /> ❑ SOLBOWNG ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING 13 YM C!ND WrIg Dla: -Offilng Ula Cashg Depth: <br /> ❑ INJECTION IAkSwftO=A& ❑ HANDAUGER GROUT SEAL DEPTH TR.EMETYPE TOBE USED. ❑AUGERS❑HOSE O.PIPE <br /> O OTHER 0 OTHER GROUT SEAL PUMPED? ❑Yea 0 No (Nota Mmdmm Freefall Daplh is 30 FI) <br /> WELUSCILBORINGIDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION.METHOD:(CHECK ALLTHAT APPLYI <br /> #WELLS TO BE DESTROYED 1 monitoring Well 91 OVER41ORE DIAMETFJRof B inches to depth of 14 feet <br /> WELL IDs MW-5 ❑PRESSIAREC#ROIIT Todepth of_feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5,5-6 gallons) ❑EXPLOSIVES From to feetbelav surface <br /> TREMIETYPETOBEUSED AUGERS ❑HGSE.[]PIPE ❑MUSHROOM CAP ❑3feet below surface or feet below surface 1>3feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 - <br /> I hereby certifythat I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaguin County Ordinance Codes and Standards,and all other applicable California.taws. <br /> Signed S t— Title/Company PROJECT GEOLOGIST/AGE <br /> Print Name BRIAN MILLMAN Date 12/02/2015 <br /> /// DEPARTMENT USE ONLY /// <br /> Application Accepted By: '41!x�rJft!:Li/�4 Date Issued: � A/G119� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: 6`v/ j -'`/'jF <br /> Fact! !Site Information <br /> FA Name FAAddress PA# PR# <br /> FA PE I WP Reviewed 8y Wodt Plan Dalo <br /> EIC-57 ❑C5/AutlV0*Dntur O3vto Sp %m1t ❑mrwsowo ow*WsCompwaiver ❑ErvowhmmlPemt OP=ss.Apemsnt El LeedAgeecy Appeal 0AFR <br /> COMMENTSICONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RE'CV'D 8Y DATE'. SERVICE REQUEST# INVOICE# <br /> Work Plan ,rQ <br /> Permit 2992— 315 $130x <br /> EHD 29-!71 623-2015 Site Mitigation Well Permit Application <br />