FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ° cQ ORIGINAL. ENVIRONMENTAL HEALTH DEPARTMENT LOP U: . 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Iephone: (209) 468-3454 Fax:(209) 468-3433 Web: wwsiclov.ortilehd UNIT IV w. OCT 2 9 2012 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION ENVIRONMENT 11EALTH PERMIF/�SERV�C�� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M Application is here y ma e a an Joaquin County for a permit to construct andlor 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. 17-5- '60 O f Site Location 2402 Pacific Avenue Cross Street Castle-Avenue ' City Stockton Zlp 95204 API 125-60-01 Property Owner Robert Scott Address 120 23rd Avenue City Santa Cruz Zip 95062 Phone N/A All Well Abandonment 9245 Beatty Drive Suite A Sacramento 848359 Phone 1-916-363-9355 C-57 Contractor Address City Lic Adv nce eo nvironmen a Inc. aw o 6tocKton 68II22"1 - Consultant/SubCntr Address City Lic Phone 209-467-1006 Billable Party David Atwater Address P p Box 1107 _ City Stockton Zip CA' Phone 209-944-9115 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLlBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs = - ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `❑MONITORING ❑HOLLOW STEM I.' » DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _[I EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC '❑ OTHER 1, _O SOIL VAPOR PROBE ❑MUD ROTARY =DEPTH OF GROUT SEAL" TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE_FALL DEPTH IS 30 FT) a _❑INJECTION(i a Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS r r1 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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: R DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 19 #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF6.10,15 INCHES TO DEPTH OF 30-150 FT Mw-1 Mw-2, Mw-3, Mw-13, Ew-1, AW-1 through AW-7-and VW-1 thou h VW-7 WELL IDs: g "❑PRESSURE GROUT.TO DEPTH OF 30 to 92 FT BELOW SURFACE GROUT SPECIFICATIONS Portland Type II/TV ► _ ❑EXPLOSIVES FROM- •TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Q HOSE ®PIPE [D MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. >- i Project Geologist/AGE Signed zn.� TitlelCompany �i Print Name Daniel J- VillanuevaDate 10/26/2012. rr DEPART ENT USE ONLY `I SITE MAP IN UNIT IV FILE SITE ADDRESS V Z el e UG WORK PLAN DATED w,' x APPLICATION ACCEPTED BY .1- DATE IS EA GROUT INSPECTION BY FINAL INSPECTION BY �- TE r n DESTRUCTION INSPECTION BY DATE 12-Zt-► _ �� COMM ENTSICON DITI ONS: x ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED' CHECK# R RECV'D BY DATE SERVICE PO# INVOICE i REQUE/ST! PR# �Jv $125, 1 .1 �S 3� +CJ� . LAOU %a �O�ZQ IZ . SR# 1pta 072 8 3�"a? 37,, 17S v R0a PR# 2900 C-57 WC (i WAIVER Al C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ °ENCROACHMENT DOC N