FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

ORIGINIM-_ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh LOP SITE MITIGATION 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 47 E. 11th Street Cross Street North EI Portal Avenue City/State Tracy Zip 95376 APN 233-369-14 Property evana Family I rust Owner Paula I evand-tnistae Address 24692 Sand Wedge Lane City/State C-57 Contractor Advanced GeoEnv. Address 837 Shaw Road City/State Consultant/Sub Cntr Advanced GeoEnv. Address 837 Shaw Road City/State Billable Party Advanced GeoEnv. Address 837 Shaw Road City/State GIS Coordinates: X 37.739855 Y -121.425039 37.7'3 9 Q -(a( 041gj 3 Valencia Zip 91355 Phone 661 904-2133 Stockton Lic 680227 Phone 800 511-9300 Stockton Lic 680227 Phone 800 511-9300 Stockton Zip 95215 Phone 800 511-9300 LI NEW WELUBORING (CPT. GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B1 through B6 PE CODES ❑ WELL IDs AMT REMITTED CHECK # ❑ OTHER IDs DATE SERVICE REQUEST TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA OF BOREHOLE 2" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: —❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING. ❑ STEEL ❑ PVC Cl OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL Entire TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE IN PIPE 6 (M SOIL BORING [6 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED ❑ Yes E� No (MAXIMUM FREE FALL DEPTH IS 30 F-) _❑ INJECTION (i.e Ar Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland Type 1/II Cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 20 to 40 feet bsg ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING IXNo ❑ 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) # OF WELLS) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE COMMENTS 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 Regulations, and all applicable Folifornia la7 s Signed -/L Titie/Company Project Geologist Print Name Brian Mi Iman Date _�2' DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS / 7 E! V,4_&J r/ WORK PLAN DATED 13 E� a y 2 of APPLICATION ACCEPTED BY AREA GROUT INSPECTION BY FINAL INSPECTI PWAk DATE• • 2*1 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # I PR# INVOICE 35-0S- $130x 2-1:2 SR# 7f57/ RO # 3 50 �5 3C O 3500 PR # 2900 C-57 I WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC A14 Fun �o_m 71'>AIIA WELL PERMIT APP