FIELD DOCUMENTS FILE 3 - Laserfiche WebLink

Home Browse Search

AL ORIGEN �• `''y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP <: r •Za 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION • �;..-2 :-.�;;�• Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaov.ora/ehd UNIT IV �;FaR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION P66 2390 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 in compliance with San Joaquin County Development Title.Chapter 9A 115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 1403 Country Club Blvd. Cross Street Pershing Ave City Stockton Zip 95204 APN 123-232-46 Property Phillips 66 1380 San Pablo Avenue Rodeo 94572 Owner p Address City Zip Phone (510)245-4423 C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lie 485165 Phone (925)313-5800 ConsultantlSub Cntr Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Lic Phone (209)579-2221 Billable Party Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Zip 95351 Phone (209)579-2221 GIS Coordinates:X P90ef Y 12(,31 G t CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs D OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor[Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC O OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION C e A rSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT ELL IDS:See attached Workplan IN PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FTBELOW SURFACE TREMIE TYPE TO BE USED:N AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio , d all applica alifornia Laws. Signed Title/Company �r�Y�O A�Te-- PrintName �ct�v�v�� OMS¢` Date Oil-3 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS U�j 6701-NTlt, /1l U 8 t 57W,<1V4) WORK PLAN DATED C'� TOBEQ, 3� ZU APPLICATION ACCEPTED BY `I ej nxUDATE ISSUED .Z'3-1y AREA IG 99 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING NLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST I PR* 3 So $125. 7 COW-tt`k 1 .17 7 SR# COV 7 3S U3 3�i Ro# 3500 PR# 1-f 2900 C-57 WC v WAIVER j$� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT LENCROACHMENT DOC-A4— . I