Laserfiche WebLink
• • RECEIVED <br /> SAN JOAQUIN COUNTY DEC 0 3 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 HEAL <br /> Telephone:(209) 468-3420 Fax.(209) 468-3433 Web:www.sucohd.com PERMIT/SERVICES <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 42 West Beverly Place city/statelzip Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-153-14 <br /> Property Owner` Juan and Maria Ibarra Phone <br /> Address 42 West Beverly Place City/Statelzip Tracy, CA 95376 <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 GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/State/Zip Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX []STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL[I PVC❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes [I No Boring Dia: Caving Dia: Casing Depth: <br /> ❑ INJECTION IA aaaae.Omnel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROAT SEAL PUMPED? ❑Yes ❑No (Note:Masdmum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IN GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) <br /> #WELLS TO BE DESTROYED 1 monitoring well E]OVER-BORE DIAMETER of_inches to depth of_feet <br /> ,�(�, <br /> WELL IDs MW-7 r�PRESSUREGRCUT Todepthof 14 feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons)-[]EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED E]AUGERS 9HOSE [I PIPE KI MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> f San Joaquin County Ordinance Codes and Standards,and all other applicable.California laws. <br /> Signed V Title/Company PROJECT GEOLOGIST/AGE <br /> Print Name BRIAN MILL AN Date 12/02/2015 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By: /1/dL�( / �/.L/�Q�i�6f7 Date Issued: �lP <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: /y[•yyl s�� <br /> Facil.tv/Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE I IWP Reviewed By I I Work Plan Date <br /> ❑C-57 ❑C57 Authorization for Other to Sign Permit ❑Workals ComP ❑Workers Comp Waiver ❑Encroachment Pemdt ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COM ME NTSICON DITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 2902 13 $130x eW(C X23 /i S',�o0 39/e <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />