Laserfiche WebLink
= PaD(A, Environmental Health Department <br /> 0 ° Z SAN:JOAQUIN- G <br /> " COUNTY <br /> ccrFoa�'�P grows her•- <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 8010 Airport Way City/State/zip Stockton,CA 9 6 Phone <br /> Cross Street Stimson Street APN 177-260-04 <br /> Property Owner" California Army National Guard Brian Pierskalla Phone 916-854-1487 <br /> Address 3900 R eville Road City/State/zip No Hi hlands,CA 95660 <br /> C-57 Contractor License# 9060 exp 11/30/18 Phone 530-661-3600 <br /> Address 220 N East St et City/State/Zip /Woodland,CA 95776 <br /> Consultant/Sub-Contractor E Consultants License# Phone <br /> Address 3525 H land Ave S 'te 200 City/Sta izip Costa Mesa, CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANe Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SP FICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM\ND <br /> ORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMERIDRIVE <br /> BOREHO ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY THICK SS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GCTO CASING [I Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air soarae.ozone) ❑ HAND AUGER S L DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER EAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft)WELU SOIL BORING IDs PECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs IW-1,IW-2,IW-3,IW-4,IW-5,IW-6,EW-1,E)ll -2,EW-3,EW-4, PRESSURE GROUT To depth of feet below surface <br /> m <br /> GROUT SPECIFICATIONS Bentonite 5%,Portland Cee t 95% 5> 6 EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ®AUGERS [I HOSE PIPE ❑ USHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> /� San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 4/1 I Title/Co any Project Geologist/ ECM <br /> Print Name Chris Drabandt Date /13/2017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/ ates: <br /> Facill /Site Informati <br /> FA Name FA Address FA� PR# <br /> FA PE / WP Reviewed By Work Plan Date <br /> ❑G57 b G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-0108-01-17 Site Mitigation Well Permit Application <br />