COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

xo�4 t.�a SAN JOAQUIN COUNTYfttw ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 koralehd Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siaov �rFORa WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM N 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 complia with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 248 Industrial Cross Street '�4� AVK("J4-Ey City Stockton Zip 95206 APN 77-280-20 Property Owner Steve Donell, Receiver Address 12121 Wilshire, #1120 City Los Angeles Zip 90025 P ne 310-207-8481 C-57 Contractor EnProb Address P.O. Box 8093 City Oroville Lic 777007 hone 530-589-2019 ConsultanVSub Cntr Pinnacle Env. Address P.O. Box 904 City Clayton Lic Phone 925-673-5500 Billable Party Steve Donnel Address 12121 Wilshire, #1120 City Los Angeles Zip 9520 Phone 310-207-8481 GIS Coordinates:X 37.90614 Y 121.26967 CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs Soil vapor (SV-1 to SV-20) ; soil borings (SB-1 to SB-2 ) ; groundwater (GW-1 to GW-4) ❑WELL IDs ❑OTHER IDs C TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q) _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTI P CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 20❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 24 El SOIL BORING (n PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes No(MAXIMUM FREE FALL DEPTH IS 30 FT) � _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS a ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE T CONDUCTOR CASING No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: All borings to be abandoned same day as comple ion. No open boreholes left overnight. V NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) C T #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS The four temp. monitoring wells ar for grab groundwater samples to be closed same day. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby ce t I have prepared this application and t t the work will be done in accordance with San Joaquin County Ordinances,Rules and Regula' ns,and a appl'ca e a rnia Laws. Signed Title/Company Principal/Pinnacle Environmental Inc. Print Name Peter K. Cloven Date C DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS -4/ o N be-" k(l}L WORK PLAN DATED (L.t rie-j i,-> 2pt 2— APPLICATION APPLICATION ACCEPTED BY DATE ISSUED '7-I 2 AREA �69� GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION B��Olew&,5 DATE COMMENTS/CONDITIONS: 4- 20 RD ACCOUNTING ONLY: AID# FAC# PE CODES FEE IN AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �9 C $1 x d Co rQN SR# 29U 3 7� 3S (300 ) PR# (2900) C-57 WC Ii WAIVER Al C571 ETTER OF AUTHORIZATION TO SIGN PERMIT !i ENCROACHMENT