FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY 0 RECEIVED r l�r ENVIRONMENTAL HEALTH DEPARTMENT a 1w, < •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Al1G 7 4 201 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.siceht*ft""ItN TALH E SITE MITIGATION WELL & BORING PERMIT APPLICA�EaVicEsr� For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 429 WEST YOSEMITE AVENUE City/State/Zip MANTECA/CA/95337 Phone ZZ4 Cross Street YOSEMITE AVE.&JESSIE ST. APN 219-311-06 Property Owner* ELAINE CHEN Phone 2p, — �;�. Zf.•I�I Address 2028 SCHAFFHAUSEN ST. City/State/Zip MANTECA/CA/95337 C-57 Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209-467-1006 Address 837SHAW ROAD City/State/Zip STOCKTON/CA/95215 Consultant/Sub-Contractor Address:ADVANCED GEOENVIRONMENTA License# 680227 Phone 209-467-1006 City/State/Zip STOCKTON/CA//95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 125' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA NA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING [2 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 125' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Q PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs P-14,P-15 GROUT SPECIFICATIONS PORTLAND TYPE ii 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: SEE WORK PLAN DATED 11 APRIL 2016&RWQCB APPROVAL LETTER DATED I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San aquin County Ordinance Codes and Standards,and all other applicable California laws. Signed - Title/Company PROJECT MANAGER Print Name TIMO Hf/J. CUELLAR Date 08/23/2016 DEPARTMENT USE ONLY Application Accepted By: ,�e � Date Issued: 9 / i Grout Inspection By/Dates: Nue q Z I 10 15 12-51- 17 lT Destruction Inspection By/Dates: 1 Facilit /Site Information FA Name FA Address FA# 10C'2 3.3 PR# FA PE WP Reviewed By I Work Plan Date li C-57 ❑C-57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit Access Agreement E5Tead Agency Approval FR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit 9905' 313 $139 x Z l/ A 2Tb' 2(�'9� C!L'�� 3U lG 5Xe07j-77�P/ EHD 29-01 6-23-2015 Site Mitigation Well Permit Application