SR0069215 - Laserfiche WebLink

Home Browse Search

ORIGINAL o�q`''�• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP .z 1q i < 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •.- �,'p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.oru/ehd UNIT IV 4�/FOR 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. np Site Location 4th St Right of Way Cross Street N Central Ave City/State Tracy,CaZip 95376 APN NA /SOW Property Tracy, Owner City of Tracy Address 325 Civic Center Plaza City/State y Ca zip 95376 Phone 209-831-6452 C-57 Contractor Address City/State Lic Phone Consultant/SubCntrAMEC E&I Address 2101 Webster St, 12 Floor City/StatOakland, caLic 601450 Phone 510-663-4100 Billable Party Chevron EMC Address 6101 Bollinger Canyon Rd City/State Ramon, Lip 99583 Phone 925-790-6431 GIS Coordinates:X Y See attached figure. Well location is in front of 24 4th St. CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.AirSoarge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑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) 1 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: RSY-1 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS hydrated bentonite grout ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Wells were constructed w/ bentonite grout. AMEC will pull out tubing and hydrate bentonite to destroy wells. 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 California laws. Signed Title/Company AMEC E&I Print Name Heidi Dietrich-Foronda Date 3/7/14 cn DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7 7(3 g E HA)u7 Q(j7k/HCy ` WORK PLAN DATED f2W.42N Iy 2-o/y APPLICATION ACCEPTED BY J. yOr "'I"U-L DATE ISSU GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO#REQUEST PR# INVOICE �� 19012 $125 x 339 37r, emo 3-11-i4 SR# ?7-f7 29O 2 RO# (3500) PR# (2900) C-57 ✓ WC I/ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT PP