FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

46 SAN JOAQUIN COUNTYat RC4► s ENVIRONMENTAL HEALTH DEPARTMENT �/VE® 1868 Hazelton Avenue, Stockton, CA 95205-6232 MAR 15 =117 �Fo •:a Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.corm£ , , &7'q SITE MITIGATION WELL & BORING PERMIT APPLICATION/rs f�f rH 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 1206 E. March Ln. city/state/zip Stockton, CA 95210 Phone Cross Street West Ln. APN 104-160-04 PropertyOwner* DP &DK Investments Inc. Phone 510-926-7834 Address 821 Corporate Wv City/State/Zip Fremont, CA 94539 C-57 Contractor Gregg Drilling&Testing License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 ConsultanUSub-Contractor ATC Group Services LLC License# Phone 209-579-2221 Address 1117 Lone Palm Ave., Ste. 201B City/state/zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED "Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 4 IM HOLLOW STEM BORING DEPTH 2O-80 ft. 91 BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE SCh-4n. 11 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ ❑ SOILVAPORPROBE MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 1 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes M No Boring Dia: Casing Dia: Casing Depth: ElINJECTION(8p Some ne o t ❑ HANDAUGER GROUT SEAL DEPTH 2O-70 THEME TYPE TOB UUSED. ®AUGERS ❑HOSE ®PIPE ❑ OTHER XI OTHER: it knife GROUT SEAL PUMPED?_M Yes ❑No)(Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs W11 to MWI4 GROUT SPECIFIGATIONS' neat Cement 1312 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER Of_inches to depth of feet WELL IDs [I PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with Sa Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company —g r-aAr Al/ c A-7'L Print Name Date. 5//y 17 DEPARTMENT USE ONLY Application Accepted By: Date Issued:— Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information F FA Address / p� 2�vl FA# C��J C PR# O.� 0�s ( 0WP Reviewed By Work Plan Date orization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ead Agency Approval FRNS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV-D BY DATE I SERVICE REQUEST# INVOICE# Permit "DI -5/ $139, -5- 6 js 7 3CL7 y�l 3 Cz.1 v '7 �7 3c4=7 S-4 007 7/ 6S- EHD 29-01 10-26-2015 Site Mitigation Well Permit Application