COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

11" SAN:JOAQUIN a Environmental Health Department 1 '{ COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections �6g�D 3 �s 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. Shoulder area N side of Lafayette St,between CA St&American Sty p Stockton CA 95203 Job Address Cit /State/Zi Phone 209-937-8349 Cross Street CA&American Streets APN None Property Owner* City of Stockton -Public Works-Antonio Pinillos Phone 209-937-8349 Address 343 N EI Dorado St City/State/Zip Stockton,CA 95202 510-357-3677 C-57 Contractor ConeTec Drilling License# 1049248 Phone Address 820 Aladdin Avenue City/State/Zip San Leandro,CA 94577 Consultant/ ub-Contractor Ground Zero Analysis, Inc. License# PG 5234-Reynold Kablanow Phone 209-522-4119 Address 1172 Kansas Avenue City/State/Zip Modesto,CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 120 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER ® SOIL BORING 4 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Aa Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE (9 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS Cement 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 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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 I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed , ;_tl-aj'p. Title/Company Regional Manager, ConeTec Print Name✓ John Rogie Date 10-31-2019 D RTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: �� Z Destruction Inspection By/Dates: Facilit /Site Information C Ab FA Name �! �Qf' ' S3 ' FA Address �� /• ��IQ FA# 1rh�Z`vim PR# Q 5 f4 _I FA PEWP Reviewed By Work Plan Date ❑C-57 ]C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/QONDITIONS: C M,/� O -e - n tea`„_ u n �S b"f p�1� Jam' s 7 Oi�JV , O (� -t-- \`cJj WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D By DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application 155F004�1gzq