SR0066499 - Laserfiche WebLink

Home Browse Search

HEUEIVEU JAN 212013 SAN .JOAQUIN COUNTY0 2 ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue.. Stockton. CA 95205-6232 SITE MITIGATI� .( UNIT IV . - Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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 S in Joaquin County Development Title:Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 429 W.Yosemite Ave. Cross Street Jesse Avenue City/StateManteca/CAZip 95336 ApN 219-311-06 Property Bob Hua Qi&Elaine Chen Trus Owner Gress 2028 Schaffhausen Street City/State�lanteca/CAZip 95337 Phone(209)824-293 C-57 Contractor Gregg Drilling Address 950 Hov✓e Street City/State Martinez/CPLic 485165 Phone(925)313-580 Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd.,Ste 113 City/State Los Angelek/kA Phone(818'824-81 7- Billable Party Ami Adini&Assoc., Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)82.4-81 N GIS Coordinates X 37.797977 Y -121.221945 CA Latitude Longitude CONSTRUCTION WORK TO BE PERFORMED: NEIN WELLiBORING (CPT.GE!)PROBE.HYDROPUNCH.HAND-AUGER.OTHER) ❑ SOIL BORING IDs S' L- _41- 71WELL IDsMW1GA & r.1`,`116B i e s ❑ OTHER IDs 71'PE 8#OF WELLrBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING LN HOLLOW STEM DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA, _❑EXTRACTION'Vapor,Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule TYPE OF CASING: ❑STEEL 6 PVL" ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TRE\MIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑#Q^r_ _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ri_e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite cement slurry OTHER ❑OTHER: APPROX.BORING DEPTH MW16A 30'.M',11168 70' BOLTED TRAFFIC BOX OR ❑STOVE f1+? CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia_Lt..._ COMMENTS•'•"' construction per attached Well Constructlon Diagram. i NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS - CESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) OF VVELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SUR „- GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SUR _ TREMIE TYPE TO BE USED ❑ AUGERS ❑ HC�SE ❑ PIPE ❑MUSHROOM CAP AT(_3 FT) FT BELOW SUPF V�E COMMENTS _ 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify t t I have repared application and that the work will be done in accordance with San Joaquin County Ordinances. Rule Regulation a II a Ca' a laws. SIGN HERE / Signed ?- - Title/Compa ( ' 1e Print Name L/ Date U DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS "l 20 0, y055,--i 7-� 4CJE r^'y��72t''4 WORK PLAN DATED APPLICATION ACCEPTED BY .( • v c -1 DATE ISSUED -7-�3 AnE4� GROUT INSPECTION BY FIN L IRICurr 1 HATE LH� DESTRUCTION INSPECTION BY DATE - COMMENTS'CONDITIONS: — - :COUNTING ONLl AID# FAC# 'E CCDES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE R04 IN" GI• pp REQUEST PR# S 125x 1 / Z5 �� Cour(lT�f? �'ZY-/3 SR# RO# (3500) PR# 2900 `7 WC I/ WAIVER /L/ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09112 WELL PERr,t