FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

0 • RECEIVED aoe` t. o SAN JOAQUIN COUNTY OCT 28 2015 e —`` ENVIRONMENTAL HEALTH DEPARTMENT w: < M � '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH �qa Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.ccAERMIT/SERVICES FGf� SITE MITIGATION 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 San Joaquin County Well Standards. Job Address 1700 South EI Dorado Street City/Staterzip Stockton, CA 95206 Phone 209-937-7625 Cross Street 3rd Street APN 167-033-26 Property Owner` San Joaquin Housing Investment Group, LLC Phone 209-937-7625 Address 1209 East 8th Street City/State/Zip Stockton,CA 95206 C-57 Contractor Advanced GeoEnvironmental License# 680227 Phone 209467-1006 Address 837 Shaw Road City/StatelzipStodcton, CA 95215 Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BonngsNVells Require Access Agreements or Encroachment Permits TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERDRVFN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORNG ❑ PUSH POINT(GP/CFO CONDUCTORCASING [I Yes ❑No Boring Dia: Casing Da:Casing Depth: ❑ INJECTION(Arsoeroe.Omiel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Minimum Freefall Depth is 30 Ft) WELII SOIL BORNG IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 7 29 OVER-BORE DIAMETER of 1.25 inches to depth of 5-10 feet WELL IDs VP1-VP7 ❑PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES Fran_lo_feet below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface If>3 feel COMMENTS: I hereby certifythattoohaaat I am authorized to complete this application and that the work will be done in accordance with quin County Ordinance Codes and Standards,and all other applicable California laws. Signed ca/ ZTitle/Company Staff Geologist/Advanced GeoEnvironmental Print Name Jenn1 an Date 10/27/2015 DEPARTMENT USE ONLY Application Accepted By: - /U✓�/ 01. 7 Dale Issued: IZ/I�/�� Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# PR# S�Cor.oB' FA PE WP Reviewed By I I Work Plan Date ❑C-57 ❑G57 Authoduton for Other to Sign Pemut ❑Workers Camp ❑Worker's Camp Waiver ❑Encmxhment Peirit ❑Access Agreenent ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 523 g3% 390 /2339 Cwt' /o/zc�if $,7f0075.9,06 Permit Z9 4D Z 313 $130x S ?`f'D /1339 (lWif ��Zl� fl' SROU 9d7 EHD 29-016-23-2015 Site Mitigation Well Permit Application