FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

I � I SALMON - Environmental Health Department. .� _ )I —COUNTY - V, ,, 1' Greatness groves here 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 48 Hours Advance Notice Required For All Inspections Applica0on is hereby made to San Joaquin County fora permit to construct and/or instal(the work described. This application is made in compliance With San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1lll Nary Dthe CItylState2lp Sow Phone 209-948-0129 Cross Street Argonaut Street APN 163-260-07 Property Owner` Zscky&Sons POUItrY LLC Phone 559-443-2700 Address 2020 S. East Avenue City/StatelZip Fresno,CA 73721 C•57 Contractor TEG License# 70856e Phone 916-863-8010 Address 11350 Monier Park Place Cltyl3tato)Zlp Rancho Cordova, CA 95742 ConsultantISub-Contractor Geographic Services Inc. License# Phone 916385-0202 Address P.O. Box 4517 City/State/Zip Citrus Heights,CA 95611 CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite BaringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 21v a ❑BOLTEOTRAFFIC BOX ❑STOVE PIPE ❑ EITRACTION(VapodWater) ❑ 14AMMERMVEN DIA.OF BOREHOLE r ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING CIA ® SOIL VAPOR PROBE 5 ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL. ❑PVC ❑ OTHER M SOIL BORING I M PUSH POINT(GPICPT) CONDUGTORCASING ❑Yes ❑No Boring Da: _Ca*Dia: C arh8 Depth: ❑ INJEC710NfAtsosoe.Owa1 ❑ HAND AUGER GROUT SEAL DEPTH TREMETYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:MaximumFnefaa Depth Is30Fit WEWSOILBORINGIDs aGI,SG2,ace,ace,See,owl GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth of_feel WELL ID; ❑PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES Fran_to_feetbelaysudace TREMIE TYPE TO BE USED [I AUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: Direct push boringswemporery sal gas probes at locations to 6'for soll gas sampling. At i Iocalion(GW1 boring will be installed to 20'to 30'for groundwater sampling) 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 Codas and Standards,and all other applicable California laws. Signed %" 'Ee Title/Company (,� /G¢c Print Name��„YnA ��— 'T' _ DEPARTMENT USE ONLY ,�/2 Application Accepted By: Date Issued: 7/ c Grout Inspection By/Dales: Destruction Inspection By/Da s: Facile /Site Information FA Name vol( r FAAddress ! L1J 0(—. FA# 110'L�+pt{,� PRN C)R4 3 10 FA PE WP R awed 8y / Work Plan Date / /6 C57 ❑C57AWad:abonfor0(herto Sign Pen.1 McersCpnp ❑W'adars Comp Water ❑EnomadunmPemil ❑AwessAgnsemnt ❑Lead A IwyApproval M11firt C�OM�"ENTS/CONDITIONS I U"" CR Naf1A rlc�w oQ �( »caw b� )A JWPTYPEJ PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x / i e f�--. P 0 5 0 D9 1868 E. Hazelton Avenue I Stockton, California 00's I T 209 468-3420 j F 209 464-0138 1 www.sjcehd.com EHD 29-0i 0a01-17 Sits Mia rite.Well Pia nn Appikeaon v.l p .9-tto3 5t3 6>Z� I LM 1'Zrl L Y s/LAB X Sf-0 0-116 z