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FIELD DOCUMENTS FILE 2
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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D
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DURHAM FERRY
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1600
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3500 - Local Oversight Program
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PR0544624
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FIELD DOCUMENTS FILE 2
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Last modified
7/3/2019 5:58:21 PM
Creation date
7/3/2019 3:31:32 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
FIELD DOCUMENTS
FileName_PostFix
FILE 2
RECORD_ID
PR0544624
PE
3526
FACILITY_ID
FA0005206
FACILITY_NAME
GEORGES SERVICE
STREET_NUMBER
1600
Direction
W
STREET_NAME
DURHAM FERRY
STREET_TYPE
RD
City
TRACY
Zip
95376
APN
25510004
CURRENT_STATUS
02
SITE_LOCATION
1600 W DURHAM FERRY RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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oP4`•'•IN• <br /> • SAN JOAQUIN COUNTY • RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUN 1 ZD1ZLOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s' 4WN EIQTJI <br /> WELL & BORING PERMIT APPLICATION FhHMIT/SERVICES <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1600 Durham Ferry Rd Cross Street Hwy 33 City Tracy ZiP95304 APN 255-10044 <br /> Property Trac 95304 (209) 830-6956 <br /> Owner eranishi Irrevocable Trust Address 1600 Durham Ferry Road City y Zip Phone <br /> C-57 Contractor V&W Drilling Address 3806 Duck Creek Drive City Stockton LIC 720904 Phone 209 469-7700 <br /> Consultant/Sub Cntr Geological TechnicsAddress 1172 Kansas Avenue city Modesto Lic N/A Phone(209) 522-4119 <br /> Billable Party Tera.,iani frrevocable Txvac Address 1600 Durham Ferry Road CRY Tracy Zip95304 Phone (209) 830-6956 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs ORIGINAL <br /> ®WELL IDs AS-1, AS-2 & AS-3 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —❑EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASING THICKNESS r TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER <br /> 16' to surface <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING 13 PUSH POINT(®/CPT) GROUT SEAL PUMPED:❑Yes [ No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 3 15 INJECTION('.e MrSoerds�ozonel❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM ro FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an pe loaws <br /> Signed <br /> Title/Company <br /> Print Name YNR IA) Date <br /> ellla <br /> DEPARTMENT USE ONLY ep <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I G AL1 Lij j f Lt B Ftt r u J?dl - <br /> WORKPLANDATED Jtno- 30l 2e 1f <br /> APPLICATION ACCEPTED BY ,r DAT,E/ISSUED L -I L7-1 Z AREA 1459 <br /> GROUT INSPECTION BY VI dl{. n(E_(61 INAL INSPECTION BY 11! CV-; V&61- DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> 357 $125x 3 37S.00 0247 Ir LOW f,111117— SR# 065--/ <br /> 3 ' p 3500 14 <br /> 40 ! ) <br /> J� PR# <br /> s o . 0 D 2990 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />
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