WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Environmental Health Department COUIll t Y — 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 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 94115.3, and the San Joaquin County Well Standards. Job Address 2502 Dorset Lane Citylstatelzip Tracy, CA 95377 Phone Rob MoNz(A &s)925.lee-73]7 Cross street Blackbird Court APN 238-300-08 Property Owner* Mr. and Mrs. Fisher Phone Address 2502 Dorset Lane citylstate/z[p Tracy, CA 95377 C-57 Contractor TSA Drilling / Penecore License# 906899 Phone (530) 661-3600 Address 220 N. East Street Cily/State/zip Woodland. CA 95776 ConsultenUSub-Contractor Rob MOniz-Arcadis License# Phone 925.788.7377 Address 2300,Clayton Rd Suite 400 City/State/zip Concord CA 94520 CONSTRUCTION WORK TO BE PERFORMED:*Note: OHsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH SR ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporMaler) ❑ RAMMEWDRIVEN DIA,OF BOREHOLE 3.5 in ❑MULTIPLECASINGS❑MULTI-LEVEL WELL CASING DIA X SOIL VAPOR PROBE —2—❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC D4 OTHER Teflon tubing ❑ SOIL BORING z❑�zr PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes14No Bor'rM Dia: Cning Dia: Ceshg Depth: mr❑ INJECTION rAism.ozone K% HANDAUGER GROUTSEALDEPTH TREMIETYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? []Yes 04NO (Note:Maxhnen IMefal Depth is 30 Fit WELUSOILBORING ID, B-14, B-15 GROUT SPECIFICATIONS Hydrated Benlonite Grout l'to 4'9"In DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED []OVER-BORE DIAMETER of_inches to depth of feel WELL IDs ❑PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS 0 HOSE [I PIPE /1 ❑MUSHROOM LEI belay surface or feel below surface it>3 reel COMMENTS- Aei(�eSS /�-�-N,{ T 07A 'r ►^C/Ov1�0 R'e r~' ~ Cot t", a Nrs , , o,,hx o-^ recor4r . 1 hereby certify that 1 lern authorized to complete this application and that the work will be done In accordance with San Joaquln ounty Ordinance Codes and Standards,and all other appl(lc able ACalifornia laws. Signed Title/Company phO ( / f'110CL'/ Print Name�.�(i J1 (w ec"-A Dale 11'2.0 DEPARTMENT USE ONLY Ll Application Accepted By: Date Is ad: Grout Inspection ByfDates: Destruction Inspection By/Dates: `fi Fact[ ISM e Inform Mon FA Name FAAddress OZ �f.S� FA# OOv FA PE ZC1 (00 WP Reviewed By Work Plan Date S / 6 //q ❑C-57 ❑C57YAIMwiuOonforOtherto Sign Permit ❑Workers Comp ❑Workers GanpWaWr ❑Enaoachmen(PemGl ❑Aocess Agreemen( ❑Lead AgencyAppmwal ❑MFR COMME TS/CONDITIONS: �.�-s'�,�. �rac�c - do.Alns� r�Ni ; nok SA 14Ned� (.%�116..-- 6:I1'%' � ,ff aZ. Tp�. r G MVSP �"'�'4— tip e, WP TYPE PE L SC I FEE INFO JAMT REMITTrol CHECK# I RECV'D B41 DATE L PERMIT# INVOICE# Permit 2 1? 1 3 $152x 'a't 13 1Cl 12,1&0 IM I WF v L4 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34M F 209 464-0138 1 www.sjcehd.com EMD 29-0108-01-1] ( Aa MNpation WeII PAppace4on