Laserfiche WebLink
SAN JOAQUIN COUNTY RellENVIRONMENTAL HEALTH DEPARTMENT �" VED <br /> BAR <br /> \•` —�`,� 1868 Hazelton Avenue, Stockton, CA 95205-6232 Z 4 Za17 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com EIyVj <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIOPP RM;I-i�FR HEALN <br /> For Wells and Borings Used for Contaminant Investigations and Remediation WOES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address <br /> 4707 Pacific Avenue City/State/Zip Stockton, CA 95207Phone N/A <br /> Cross Street West March Lane APN 108-160-04 <br /> Property owner* Target Corporation Phone 612-761-6385 <br /> Address PO Box 111 City/State/Zip Minneapolis, MN 55440 <br /> C-57 Contractor Cascade Drilling and Testing. Inc. License# 938110 Phone 510-478-0858 <br /> Address 120 S 23rd Street City/State/Zip Richmond CA 94804 <br /> ConsultanVSub-Contractor Arcadis License# 00571846 Phone 707-843-6032 <br /> Address 100 Smith Ranch Road, Suite 329 City/State/Zip San Rafael, CA 94903 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> [:1INJECTION(Air Sparge.Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 13 ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs See Comments ❑PRESSURE GROUT To depth of uo to 65 feet below surface <br /> GROUT SPECIFICATIONS See Comments ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [-]AUGERS ®HOSE [-]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: WELL IDs:VW-4.SP-1.3M.SP-3.SP-4.SP-5.SP-6.SP-7.SP-8.SP-9.SP-10.SP-12.SP-13 <br /> Water-to-grout ratio of 4 gallons of water to two 47-pound bags (94 pounds) of Type IN Portland Cement. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed \.( I�� S )L�. (, t, ��.t Title/Company Principal Geologist, Arcadis <br /> Print Name Katherine Brandt Date 01/20/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Permit $139 x <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />