Laserfiche WebLink
ORIGINA( <br /> SAN JOAQUIN COUNTY <br /> T., ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> kilN. [ <br /> ' `•' 1868 Hazelton Avenue, Stockton. CA 95205-6232 SITE MITIGATIdN <br /> UNIT IV ; <br /> one: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �\I WELL & BORING PERMIT APPLICATION <br /> RE � <br /> C 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 Jog County for a permit to construct and/or install the work described. This application is made in compliance with S n <br /> Joaquin County Dev le pp fjT er 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1 T�'�Ww1-l�tvenue Cross Street Rose Lane City/State Manteca/CAZip 95336 APN 219-311-08 <br /> Property John &Ann Christensen Trust 349 Scenic Place Manteca/C <br /> Owner Address CityiState ASI) 95337 Phone(209)239-764.- <br /> C-57 Contractor Gregg Drilling Address 950 Howe Street City/State Martinez/CPLic 485165 Phone(925)313-58C0' <br /> Consultant/Sub Cntr Ami Adini&Assoc. Address 4130 Cahuenga Blvd.. Ste 113 City/State Los Angelek/PA Phone(818)Std-81 Gs <br /> Billable Party Ami Adini &Assoc.. Inc. Address 4130 Cahuenga Blvd., Ste 113 City/State Los AngelesZip 91602 Phone(818)824-810k <br /> GIS Coordinates.X 37.797977 Y -121.222287 CA <br /> a l U e o—ng l u e - <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING$ <br /> ®WELL IDs <br /> ❑OTHER IDs <br /> TYPE&##OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS n <br /> _X1 MONITORING LN HOLLOW STEM DIA.OF BOREHOLE 12° IN MULTIPLE CASINGS 6 MULTI-LEVEL WELL CASING DIA: 2 <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL 6 PVC ❑ OTHER — <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5'Annular TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑ E <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes KI No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e .Lir Sparoe.Ozohe)❑HAND AUGER GROUT SPECIFICATIONS f3vrrtonile-cement slurry <br /> ❑OTHER ❑OTHER APPROX.BORING DEPTH 70 [N BOLTED TRAFFIC BOX OR ❑STOVE Fji: <br /> CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia _ <br /> COMMENTS Well construction per attached Well Construction Diagram. <br /> —._ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS t--- <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> 9 OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF�P"f <br /> WELL IDS' ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFVIE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURF ktIPF <br /> TREMIE TYPE TO BE USED [-]AUGERS ElHOSE ElPIPE ElMUSHROOM CAP AT(>3 FT) FT BELOW SLIRF.'aCF <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that hav r ared t lication and that the work will be done in accordance with San Joaquin County Ordinances, Rules'at�d <br /> Regulations, a_I aws. <br /> scN Title/CompanyC - p7 �U /l Signed C �/ / o / ( r <br /> Print Name +ClVZ wwo­ Date la ' Sr <br /> L/ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS -7 2O W, ,bSE-+'1(TC- iiyr, - y ely7Eef! <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY J• 19 ICkH'l DATE ISSUED 10-21T-( 2- AREA t&Cfq. <br /> GROUT INSPECTION BY FINAL ghwy,'6D <br /> ` <br /> oA N(. DATE /-j t[� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS.!CONDITIONS: <br /> k <br /> Ci?TINTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICIR <br /> p QQ REQUEST PR# _ <br /> x SR# <br /> c . <br /> 2 fv �7S 3 00) <br /> PR# <br /> 2900 <br /> C-57 WC _L /t/ <br /> WAIVER ([— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC—� <br /> EHD 29-01 5/09/12 WELL PERMIT <br />