Laserfiche WebLink
s <br /> t � <br /> SAN JOAQUIN COUNTY <br /> 3. �o <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N` 600 East Main Street, Stockton, CA 95202-3029 SITE UNIT MITIGATION <br /> �;..:• :.�;;P Telephone: (209)468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> /FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 2 3 <br /> Site Location 11 W 6th St Cross Street N Central Ave City Tracy Zip 9537 6 APN—9-- $���-- <br /> Property UPRR 1400 Douglas St. stop 1690 Omaha Ne 6817 <br /> Owner Address City Zip Phone 4 0 4—5 4 4—8 5 6 4 <br /> C-57 Contractor Penecore Address1238 Alice Ave.suit ACity Woodland Lic 906899 Phone 530-661-3600 <br /> Consultant/SubCntr AMEC Address 101 Webster St. 12 FloorCityOa}Clarid Lic 601450 Phone510-663-4133 <br /> Billable PartyChevron Env Mgt COAddress6101 Bollenger Canyon RdcitySan Ramon Zip 94583 Phone 925-790-6437 <br /> GIS Coordinates:X Y See attached figure <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NE®SOIL BORING BORING IDs JOuphBEPDROPUNCH,HAND-AUGER,OTHER) <br /> El WELL IDs l <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes IR No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoame.ozone)QHAND AUGER GROUT SPECIFICATIONS Type I/II Portland Cement grout <br /> _❑OTHER: P OTHERdirect push APPROX.BORING DEPTH 25 ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING b No❑Yes:Casing Dia: Casing Depth: Boring DIa: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and II ao��o,lliyic�..,a�-blle�e,Ca,lifornia Laws. <br /> Signed 'owA"tlw.tkc Title/Company Staff Scientist/AMEC <br /> Print Name Heidi Dietrich-Foronda Date June 5, 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 1J (,T-" <br /> WORK PLAN DATED S"'VC, -?— <br /> APPLICATION <br /> APPLICATION ACCEPTED BY DATE ISSUED C4-542- AREA 16`I <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> C REQUEST PR# <br /> $125x �ZJ 2�uUy�� P ��2 SR# l¢JrU�2 <br /> v 3S S 75- 350o <br /> PR# <br /> 2900 <br /> C-57— WC WAIVER A/(fir C57 LETTER OF AUTHORIZATION TO SIGN PERMIT li ENCROACHMENT DOCS <br />