FIELD DOCUMENTS FILE 2 - Laserfiche WebLink

Home Browse Search

Fo SAN JOAQUIN COUNTY copy�`� ENVIRONMENTAL HEALTH DEPARTMENT Lop . . 1868 Hazelton Avenue, Stockton, CA 95205-6232 r MUNED <FO..% Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd < R WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION`'' r ® Z�i4 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 maENARONMENTAL HEALTH de irPF,'#Rb."l Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 7-Eleven Store#19976(off-site wells) RoW Site Location 1399 North Main Street Cross Street Northgate Drive City/State Manteca zip 95336 APN 216-330-34 Property Owner City of Manteca DPW Address 1001 W. Center Street City/State Manteca zip 95337 Phone 209-456-8400 C-57 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond Calc 953646 Phone 510-236-6282 Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road, Suite 100 City/State R.C. CA Lic 952595 Phone 916-384-0724 Billable Party 7-Eleven Inc. clo Stantec Address 3017 Kilgore Road, Suite 100 City/State R.C. CA Zip 95670 Phone GIS Coordinates:X 37. Y 12-C 2171 L/ Permit Coordinator:Debbie Lichtenberger 916-384-0724 debbie.lichtenberger@stantec.com Project Manager:Danielle Manning 916-384-0706 danielle.manning@stantec.com 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❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Soarae.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 & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-4 MW-4A MW-7 ® PRESSURE GROUT TO DEPTHOF 30 to 53 FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ®PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Wells to be destroyed Der the attached SJCEHD letter dated April 17 2014 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatio nd II applicable California laws. Signed A444APbA&A Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenbe er Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 13 4.l 1V' !Mo l'J WORK PLAN DATED �C j52uf}R`S 1 201`1 APPLICATION ACCEPTED BY I '�D Ku wl DATE ISSUED la 1/—r t_l AREA G ClQ GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# CE RO# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVIREQUE/STo c�PR# INVOICE 3-So 2 $125. `` Lf'3C)('U / oc,,v -30-11/ SR# tQ lC1J� RO# -3103 9 J7 S 3500 PR# 2900 C-57 ✓WC ✓ WAIVER T/ - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _gZ ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 5/09/12