Laserfiche WebLink
RECEIVE <br /> � • RECEIVES <br /> FEB O1 2016 <br /> SAN JOAQUIN COUNTY <br /> OCT 28 2015 <br /> ENVIRONMENIENViRONMENTAL HEALTH DEPARTMENT <br /> EALTH DEPARTM§bgHazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> k ry Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:A A.sicehd.ccAEgMIT/SERVICES <br /> SITE MITIGATION 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. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 1700 South EI Dorado Street City/Stateop Stockton,CA 95206 Phone 209-937-7625 <br /> Cross Street 3rd Street APN 167-033-26 <br /> Property Omer* San Joaquin Housing Investment Group,LLC Phone 209-937-7625 <br /> Address 1209 East 8th Street City/State/zip Stockton,CA 95206 <br /> C-57 Contractor Advanced GeoEnvironmental License# 680227 Phone 209A67-1006 <br /> Address 837 Shaw Road City/State/zipStockton,CA 95215 <br /> ConsultanVSub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 <br /> Address 837 Shaw Road City/5tatefZip Stockton,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORINGOEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE Pff <br /> ❑ EXTRACTION(VapaM'ater) ❑ HAMME WMN a0.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:.❑STEEL ❑PJC❑OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPO CONDUCTORCASMG ❑Yes 0N Being Dw: Casing Dia Casing Depth: <br /> ❑.INJECTION.Nrsoar ownel ❑ HANDAUGER GROUT SEAL DEPT THEME TYPE TOBEUSED. ❑AUGERS ❑HOSE❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes❑No.(Note:MadnemFreefall Depth is 30 Ft) <br /> WELUSpl BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 7 P9OVER-BOREDIAMETERof 1.25 Inches to depth of 5-10 feet <br /> WELL IDs VP1-VP7 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From fi_feet below surface <br /> TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOMCAP ❑3feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> --5 n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 6� Title/Company Staff Geologist/Advanced GeoEnvironmental <br /> Print Name Jenn'Ifie tan Date 10/27/2015 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: bio Date Issued: <br /> Grout inspection By/Dates: r <br /> Destruction Inspection By/Dates: <br /> Faclli /Site Information <br /> FA Name I FA Address I IFA# I I PW <br /> FA PE I WP Reviewed By I I Work Plan Date <br /> 005/ 0G6 Authorization for Otherb Permit ❑Vlbrkets Comp ❑workefs CompWaim ❑Enceoechmml Pemtit ❑A=sAgreement ❑lead AgarcyApproval ❑PIFR. <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> WotkPlan 2903 $23 Com? i"/"'alf $ Oc739a4 <br /> Permit 7-90Z 313 130 x S ,it`dsit /713 9 (44*R /o4,U- 5900 907 <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />