FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

RECEIVED oA41'� SAN JOAQUIN COUNTY DEC 0 2 2015 ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH w. 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SERVICES �;•.- ;p Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made incompliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address $Ool, We-&TLWl)bEr Pr kn A( City/statelZip ,��eJ/L � fA cfS7;L03 Phone Al# Cross Street _A/prK ��,.�.r�� k AP 13 7' -3'}O -O 1 Property Owner' - 1 137-370-02 for SSGP-1 Phone a004 -11?3 -4v2-'L Address D 0 1 City/State/Zip 5 Le—Owm cA S 1,23 C-57 Contractor T 1P G- License# Phone I t0 Address I,A 15-0 M 0 a, 0` City/State/Zip {j;„,�fto C&r".,T L Consultsnt/Sub-Contractor yry'}w c5enti s License# Phone 01 0400 Address 3 OI-�- IL: Soa . 4Z , g-" ('o City/State/Zip Qc."-�'o Cor --' C/5 gAr+o CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH r 1 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) HAMMER/DRIVEN DIA.OF BOREHOLE / of ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA IS SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESSy/jf If do TYPE OF CASING: ❑STEEL [3PVC PW OTHER Te I-I on [3SOIL BORING C1PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia r Of Casing Dia: 1/Q l I Casing Depth: ❑ INJECTION(AV soaw.ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERSHOSE ❑PIPE ❑ OTHER ❑ OTHER: GROAT SEAL PUMPED? ❑Yes❑No (Note:Maximum Freefall Depth is 30 Ft) ' WEWSOIL BORING IDs '00'c✓.+3ti GROUT SPECIFICATIONS wqlk&-NAj- � C, ro�� ,r Cu.l 1 15 e-P - 13 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: '6vM J' pc C. , 1..-d If • ✓G6 v' ^'fes S�Hr1tI'J'� 14, I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin"County Ordinance Codes and Standards,and all other applicable California laws. rfs1 Signed � �_ (•H/h•y Title/Company AiSdc-,'c& SL.',i^ S SN►t1t� Print Name Date DEPARTMENT USE ONLY Application Accepted By: /(/-'�% % ,L�, r i l / Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: % ;,n.f h, Jc.•°/yl S3L-j� Z 74..- -5 L'& L--,a. �j�i�G� b�•.`'�s cv�� x%; fled r pwfe�.tt vI«�f-, SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan2 q Permit ,.�G� -jI 130x j9C 22`/ `a C j ✓�C c j� EHD 29-016-23-2015 Site Mitigation Well Permit Application