COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

S A N sJ Q A Q� � N Environmental Health D artment T RECEIVED SITE MITIGATION WELL Bit BORING PERMIT APPLICATIO OCT 0 3 201 For Wells and Borings Used for Contaminant Investigations and Remedia NuROWENTI,, P NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERMIRSERIIGES 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 Louise Avenue 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/State/Zip 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [N MONITORING 1 ❑ HOLLOW STEM BORING DEPTH Up to 300 ft bgs ❑BOLTED TRAFFIC BOX ®STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE B" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 4 a-r L ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS O.Z,14;M TYPE OF CASING: RSTEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air$me.Owner ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ©PIPE ❑ OTHER ® OTHER Sonic GROUT SEAL PUMPED? M Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs PW45 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 ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: One monitoring well will be installed to a maximum depth of 300 ft bgs. See attached table with well specifications. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with -SarrJoaquin County Ordinance odes and Standards,and all other applicable California laws. Signed Title/Company Professional/Geosyntec Consultants,Inc. Print Name Garrett Thornton Date October 2,2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name ! FA Address FA# (22.`til PR# FA PED tlVAtt WP Reviewed By L Work Plan Date t ❑C-57 57 Authorization for Other to Sign Permit ork& Comp [I Workers Comp Waiver ❑Encroachment Permit Y(-ess Agreement Lead Agency Approval E FR COMMENTS/CONDITIONS: WP TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV`DDBY DATE v WELL PERRMiITT##j INVOICE# Permit L`ti0 3 f3 $152 x I $ �.1 Z r1 3Z L J C�ILp lrJ P00 3°0 0 Gf 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application P "jA/r.5 !;-L'