COMPLIANCE INFO_CASE 2 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FILE s OW_�. <� i �•� 600 East Main Street, Stockton, CA 95202-3029 UNIT IV � q�.. ••..N;P� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.si-ov.org/ehd WELL & BORING PERMIT APPLICATION 4V/R FOR WELLS NONND BREFINGS USED FOR UNDABLE PERMIT EX PIRES 1 YEAR FROM DATONS AND E ISSUED EMEDIATIOIt�R��SFRV N�LT ICES h 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. site Location 3736 Highway 99 Cross Street Carpenter Road city Stockton zip 95215 APN 179-160-03 Property Owner Donald Roek Address PO Box 30038 City Stockton Zip 95213 Phone 209-610-8344 C-57 Contractor Advanced GeoEnvironmental,Inc Address 837 Shaw Road city Stockton Lic 680227 Phone 209-467-1006 dvance Consultant/Sub Cntr� oenv omental ln� Address 837 Shaw Road city Stockton Lic 680227 Phone 209-467-1006 Billable Party AdvancedGee7oEAvironmental,Inc Address 837 Shaw Road city Stockton zip 95215 Phone 209-467-1006 GIS Coordinates:X 17.T? ZZ Y — (Zr, zz CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs 131 132, 133. 134. B5 and 136 ❑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: [ISTEEL [IPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Max 25' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ELM SOIL BORING J$i PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Type 1/11 Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10' and 25' ❑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) #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 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that stave prep dlication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and/7W plica California ws. Signed Title/Company President / Advanced GeoEnvironmental, Inc. Print Name Ro ert E.CMarty Date 24 January 2012 DEPARTMENTUSEONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 3 7 WORK PLAN DATED APPLICATION ACCEPTED BY J - 4 D I4K LAP i DATE I ^/ t G 4 GROUT INSPECTION BY FINAL INSPECTION BY Ail157— DESTRUCTION INSPECTION BY DAT COMMENTS/CONDITIONS: /✓� jr ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUE/S/Tr PIR# 9 v5 $125 x - -� SR# 3 Ro# (3500) PR# _ (2900) C-57 WC WAIVER_ C57 LETTER OF AUTHORIZATION TO SIGN PERMIENCROACHMENT DOC�� FILE Cblt