Laserfiche WebLink
P� 'I SAN JOAQUIN COUNTY � ORIGINAL <br /> a•.r!'si''Fq <br /> x ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> 7F'o'•' <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/eh UNIT IV <br /> WELL & BORING PERMIT APPLICATION <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 15135 Eight Mile Road Cross Street Correia Road City/State Stockton Zip 95219 APN 069-080-21 <br /> Property. <br /> m'Delta Farms Reclamation District 2024'dreg$ W <br /> 421 South E1 zado Street Suite 6 Stockton 209- <br /> FW City/Stateocon Zip 9520) Phone 946-9675 <br /> C-57 Contractor All Well Abandonment AddreSS3369 Fitzgerald Road Suite E Rancho Cordova 848359 916-363-9355 <br /> City/State Lic Phone <br /> Advanced pe°Envir°nmental Inc. 837 Shaw Read Stockton 680227 209-467-1006 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Advanced Geoenva mental lncAddress, e37 Shaw Road City/State Stockton Zip 95215 Phone 209-467-1006 <br /> GIS Coordinates:XO3V, v ^/z 1.Y99 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDS <br /> ❑OTHER IDS <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION a.,Air Sparge.Ozone)❑RAND AUGER GROUT SPECIFICATIONS <br /> _[]OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR O 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 /> J--#OF WELL(S)TO BE DESTROYED DOVER-BORE DIAMETER OF 6" INCHES TO DEPTH OF I41 and e�T <br /> WELL IDs: MW-11. Mw-12 and MW-13 ❑PRESSURE GROUTTO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS F°nland cement (6 gallons per 94 lbs bag) ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:171 AUGERS EI HOSE 0 PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify th I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a at appl' able California laws. {;1A <br /> sri <br /> Signed Q Title/Company Project geologist 'J1A�3 ��- <br /> lasitit , <br /> Print Name �naaie villanueva Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS / / &&gyT A o <br /> WORK PLAN DATED A rRi / <br /> APPLICATION ACCEPTED BY ,-lino to w1 DATEISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY r DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 702 $130, 3 390 /1 Y2.2 CpouluMkN 3-y5 SR# <br /> RO# <br /> 3500 <br /> is o S 32 <br /> C-57 ✓ WC WAIVER Wig- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ENCROACHMENT DOC A-�4 <br /> EHD 29-01 7/24/14 WELL PERMITAPP <br />