Laserfiche WebLink
SAN JOAOU } N Environmental Health Department <br /> I <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED y / <br /> 48 i-IOUrs Advance Notice Required For All InspectioriB -/ 6 0 <br /> i <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 2502 Dorset Lane CitylstatelZip Tracy, CA 95377 Phone Rob Mamz(N.ds)925J8&7377 <br /> Cross Street Blackbird Court APN 238-300-08 <br /> Property Owner' Mr. Heredia Phone <br /> Address 2502 Dorset Lane 11 City/State(Zip Tracy CA 95377 <br /> C•57 Contract kPeneeore /?54 I]rl { kut�__License# 906899 Phone (530) 661-3600 <br /> Address 220 N. East Street City/Stale/Zip Woodland, CA 95776 <br /> Consultant/Sub-Contractor Rob Moniz-Arcadis License# Phone 925.788.7377 <br /> Address 2300 Clayton Rd, Suite 400 City/StatelZip Concord CA 94520 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offate BoringsMlells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH In it ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaPWMaX') ❑ HAMMERDRIVEN DIA.OF BOREHOLE 351n ❑MULTIPLE CASINGS❑MULTI LEVEL WELL CASING CIA <br /> M SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC XOTHER Teflon tubing <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ;4No Boring Dia Casng Ole: Casing Depth: <br /> ❑ INJECTION IM soxae panel X HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes JK No (Noe:Ma'rlmum Freetal Depth is 30 FQ <br /> WELL)SOIL BORING IDS B-13 GRWTSPECIFICATIONs Hydrated Bentente Grout Tto Ng"in <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALLTHATAPPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL IDs ❑PRESSUREGROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below sudace it>3 feel <br /> COMMENTS: <br /> liter y certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company e7—o <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> Application ccepled By: �Q� i <br /> Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili[ /Site Information �s/1 <br /> FA Name FAAdrtress G �Z FA# vr� 7 jj� PRI <br /> FA PE 12A WP Reviewed By Work Plan Date / <br /> C.57 ❑C57 Authorizationior01herto Sign Permit ❑Workees Comp ❑Workers Compwaver ❑Encroachmenl Pertdt ❑Aaess Agreem�eem 11Le enyAmmV8I ❑MFR <br /> COM EN S/CONDITIONS:Sub�� ,yT/7 "A � S ms <br /> C / G/� f. <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE - WELL PERMIT INVOICE# <br /> �y7 <br /> Permit 'A 3 $152 x C. - 12 W V <br /> 10 0 Hgzeiton Avenue i Stockton, California 95205I T 209460M,,- j F 209 464-0138 i www.sjeehd.com <br /> Y Site MiligeVoo Well Permit App ammn <br /> (�,, '�cr Nt�� , 9�i4/Zo2o s /�oaar5sw <br />