FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

osaW SAN JOAQUIN COUNTY '..r C R I G I + v` ► I x•++EE .O ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • •. :.;:�• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org ...... /ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 308 S. El Dorado Cross Street Lafayette St. City/State CA Zip 95203 APN 149-063-01 Property Owner Den Ueda Address 626 East Galin Road City/State French CampZip 95231 Phone 209-462-1262 C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City/State Sacramento LIC 848359 Phone 916-363-9355 Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 680227 209-467-1006 Consultant/Sub Cntr Address City/State Lic Phone Billable Party Den Ueda Address 626 East Galin Road City/State French CampZip 95231 Phone 209-462-1262 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ©HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER_ ❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS I!]HOSE E]PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.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 S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 85,65,120 #OF WELLS)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 & 12 INCHES TO DEPTH OF FT WELL IDS: Mw-IA/B, MW-2A/B,MW-3A/B MW-4, MW-5, MW-6, MW-7 ©PRESSURE GROUT TO DEPTH OF 65 FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type I/II ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[!]AUGERS Fx1 HOSE El PIPE E]MUSHROOM CAP AT(?3 FT) 3 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certif a have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, nd all icable California laws. Signed Title/Company Project Geologist Print Name Daniel Villanueva Date 05/13/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 30U --.CL WORK PLAN DATED R I V o APPLICATION ACCEPTED BY J. DATE I U GROUT INSPECTION BY FINAL INSPECT N BY I��jS AZE DESTRUCTION INSPECTION BY r DATE f COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125 x 7 V SR# / RO# 35c>-3 375 (3500) PR# (2900) C-57 WCy WAIVER (d/4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC A-., EHD 29-01 5/09/12 WELL PERMIT APP