FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

RECEIVED SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTJUN 2 2 204 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTALHEgLTH Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com PERMIT/SERVfLES �rFORC� SITE MITIGATION 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 San Joaquin County Well Standards. Job Address 4707 Pacific Avenue City/State/Zip Stockton, CA 9520713hone N/A Cross Street West March Lane APN 108-160-04 Property Owner* Target Corporation Phone 612-761-6385 Address PO Box 111 city/state/zip Minneapolis, MN 55440 510-478-0858 C-57 Contractor Cascade Drilling and Testing, Inc. License# 938110 Phone Address 120 S 23rd Street City/State/Zip Richmond CA 94804 Consultant/Sub-Contractor Arcadis License# 00571846 Phone 707-843-6032 Address 100 Smith Ranch Road, Suite 329 City/State/Zip San Rafael, CA 94903 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 12 ®OVER-BORE DIAMETER of 3/4 inches to depth of 65 feet WELL IDs See Comments ❑PRESSURE GROUT To depth of uD to 51 feet below surface GROUT SPECIFICATIONS See Comments ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS ®HOSE ❑PIPE El MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: WELL IDs:Pressure Grout:VW-4 Overdrill•SP-1 SP-3 SP-4 SP55SP- SP-f SP'8 SP-9.SP- 0.SP- 2 SPA VW-4 to be pressure grouted due to utility hazards Water-to-grout ratio of 4 gallons of water to two 47-pound bags (94 pounds)of Type HV I hereby certify that I am authorized to complete this application and that the work will be done in accordance with I• San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed '�i"\�� ir`( C.!. ( �� Title/Company Principal Geologist, Arcadis Print Name Katherine Brandt Date 06/05/17 DEPARTMENT USE ONLY 6 Application Accepted By: Date Issued: `'/ / Grout Inspection By/Dates: / 1 Destruction Inspection By/D es: F 50 13 flo—j Facili /Site Information pud + S FA Name "� FA Ad ress b � FA# PR# Q S� rfly FA PE WP Reviewed By Work Plan Date 16 G57 ❑C-57 Authorization for Other to Sign Permit Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency/Approval FR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# PermitZ916Z_ $139 x Sr L' (-0.7 7 OP -M 03 ori 7 St, 60 7723 `7 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application