COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAID 1OAHIN Environmental Health Department 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 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 16888 McKinley Road City/State/Zip Lathrop/CA/95330 Phone 209-858-3365 Cross Street Lague Road APN 19816026 Property Owner' Super Store Industries Phone 209-858-3365 Address 16888 McKinley Road _ City/State/Zip Lathrop/CA/95330 C-57 Contractor Yellow Jacket Drilling Service,LLC License# 1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State2ip Rancho Cucamonga,CA 91730 Consultant/Sub-Contractor Geosyntec Consultants,Inc. License# Phone 916-637-8334 Address 3043 Gold Canal Dr. _City/State/Zip Rancho Cordova,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING 1 ❑ HOLLOW STEM BORING DEPTH Up to 300 ft bgs ❑BOLTED TRAFFIC BOX I29 STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 1-` ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑OTHER ❑ SOIL BORING ❑ PUSH POINT(GP!CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth ❑ INJECTION(Air Spam,Qum ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Q PIPE ❑ OTHER Q OTHER: Sonic GROUT SEAL—� Q Yes []No (Nate:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs ^I [W r�o GROUT SPECIFICATIONS Type II-V 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 F-1 PIPE E]MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 1 monitoring well will be installed to a maximum depth of 300 it bgs. See attached table with well specifications. I hereby certify that I am authorized to com lets this application and that the work will be done in accordance with San Joaquin Co nce Codes and Standards,and all other applicable California laws. Signed Title/Company Geologist/Geosyntec Consultants, Inc. Print Name Garrett Thornton Date October 29,2018 DEP TMENT USE ONLY Application Accepted By: a. Date Issued: \\ 1 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information �I FA Name SlNt �fi FA Address r1i'.1 1 Ha-"1tawl rel FA# i')C)'L `? y PR# FA PE WP Reviewed By Work Plan Date [3P-57 5/Authorization for Other to Sgn Permit E:" orkers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ccess.Agreement ead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit }r'1 C' { $152 x . ,` v-'t L. t, a l 1868 E Hazelton Avenue I Stockton, California 95205 j T 209468-34201 F 209464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application