Laserfiche WebLink
SANJOAQUIN <br /> Environmental Health Department <br /> —COUNTY— <br /> e- <br /> °11 l `P Greatness grows here. OCT 13 RCCTI <br /> SITE MITIGATION 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 /> 48 Hours Advance Notice Required For All Inspections <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 2417 N West Lane City/State/Zip Stockton CA _P Phone 209466.4725 <br /> Cross Street Klinger Road APN 117-090.08 <br /> Property Owner' Sue Rokoszewski Phone 209.466.4725 <br /> Address 2417 N West Lane CitylState/Zip Stockton,CA <br /> C-57 Contractor Environmental Control Associates License# C57#695970 Phone 831.662.8178 <br /> Address 3011 Twin Palms no. City/State/Zip Aptos CA 95003 <br /> Consultant/Sub-Contractor Hydrogeological Associates License# PG#7299, CHG#961 Phone 91fi-761-3700 <br /> Address 3230 Arena Blvd,#245.373 City/State/Zip Sacramento, CA 95834 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Ogsite BoringstWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10-15' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporM7ater) ❑ HAMMERNRNEN DIA.OF BOREHOLE 7 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ID PVC ❑ OTHER <br /> "� SOIL BORING 3 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Die: Casing Dla: Casing Depth: <br /> ❑ INJECTION IN,Sow,o 1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is 30 Fl) <br /> WELU SOIL BORING IDS SB-1 SB-7 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feel <br /> WELL IDs ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> reby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> S rr,lloaq in Cou y Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Principal Hydrogeologist Hydrogeological Assoc <br /> Print NameThomas E.Ballard Date 914/17 <br /> DEPARTMENT USE ONLY J1 j 2 ,� <br /> Application Accepted By: Date Issued: l/ `7 <br /> Grout Inspection By/Dates:: <br /> ���� \ V <br /> Destruction Inspection By/Dates: <br /> Factlit /Site Information 'e-�— <br /> FA Name S� FA Addis -7 FA# �j+(j0U-� PR# o�z3601 <br /> FA PE � WP Reviewed By Work Plan Date 7�i / 7 <br /> C57 ❑C-57AuthWzetionfmolherlo Sign Permit Workers Comp ❑Workers Comp star [I Encroachment Permit ❑Access Agreement ❑Lead Ag cyApproval FR <br /> COMMENTSICONDITIONS: GCp, M044 )> -- Y1 (0/ `'I - � Cv`^r� a c1leti <br /> 4n ,+ 1u Sl V Ll9R uyj u 0-00' VV <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> enw `Taos' 3, 3 � 3 7I, ys6 /OS-3 MA-- fj 003731 L <br /> 1868 E. Hazelton Avenue j Stockton, Califr is 95205 j T 209 468-3420 i F 209 464-0138 ajo www.sjcehd.com <br /> l/P E"� 31A7 4 �, �' �l, �3 ,.1,,-- s � vo , �"r3eAu <br />