COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

fQ�QU1N _ GZ SANAAQUIN Environmental Health Department COUNTY Greatness grows here. PAXOM SITE MITIGATION WELL & BORING PERMIT APPL1 1JTI dJJt�8 For Wells and Borings Used for Contaminant Investigations an��dyy��R��@@ d ��##Icct�111�� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS".ONMENT HEALTH 48 Hours Advance Notice Required For All InspectionsPAR 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 1501 S.Airport Way City/State/Zip Stockton,CA 95204 Phone 209-951-8228 Cross Street Airport Way &1st Street APN 169-020-11 Property Owner City of Stockton Phone Address 400 E.Main Street,4th Floor City/State/Zip Stockton,CA 95202 C-57 Contractor Advanced GeoEnvironmental,Inc. License# 610 OR-07'Zi Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor A.G.E. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton/CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10',20',50' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA na ® SOILVAPOR PROBE 8 ❑ MUD ROTARY CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER na ® SOIL BORING 4 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: na Casing Dia: na Casing Depth: na ❑ INJECTION(Air Sparge.ozonel ❑ HAND AUGER GROUT SEAL DEPTH 10',20',50' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ©No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SV2(ABC),SV3(ABC) GROUT SPECIFICATIONS Portland Type II SV4(6BC) SV5(ABQ 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 attached Site Assessment Work Plan I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Manager/A.G.E. Print Name Timothy J.Cuellar Date 08/02/2018 DEP T USE ONLY G Application Accepted By: Date Issued: Grout Inspection By/Dates: �✓� Destruction Inspection By/Dates: Facilit /Site Information i ocV- r' vt 1v�'rnt �1 FA Name FA Address (50I S.A.�.�,.�'T V�^-� FA# 1(20Z-C7')0 PR# FA PE C� WP Reviewed By (_ Work Plan Date 57 ❑C-57 Authorization for Other to Sign Permit orker s Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATEt WELL PERMIT# j INVOICE# Permit ?�t'j �I� $152x .`il-i 1,..-Y to c7i 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OB-01-17 Site Mitigation Well Permit Application t�P ?-,I os 5-Z3 '�- lsZx 3 �lsb zy�s —X �1�1�8 5'""