BILLING/PERMITS_2017-2018 - Laserfiche WebLink

Home Browse Search

9 SAN JOAQUIN COUNTY a W.W%0L.I V L.0 MAR 2 9 201? ENVIRONMENTAL HEALTH DEPARTMENTEWRONMEN; P 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMIPSERtlIGAT10N Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.oru/ehd RNI IV WELL & BORING PERMIT APPLICATION 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 Standards of the San Joaquin County Environmental Health Department. Site Location 17100 Murphy Parkway Property Owner ASP/RWM Properties, et al C-57 Contractor Cascade Drilling Consultant/Sub Cntr Brusca Assoc., Inc. Cross Street D'Arcy Parkway City/State Lathrop, CA Zip 95330 APN 198-012-009 Address 1200 Concord Ave. Ste. 200 Address 3000 Duluth Street Address PO Box 332 Billabl® Partv Brusca Assoc., Inc. Address PO Box 332 GIS Coordinates: X 37.806 Y -121.287 9?-,Sc/t- ASs0 City/State Concord/CA Zip 94520 C Phone (925) 674-8400 City/State West Sac., CALic 938110 Phone (916) 638-1169 City/State Roseville, CALlc CEG#1948 Phone (916) 677-1470 City/State Roseville, CAZip 95661 Phone (916) 677-1470 . -DIEC . 3 5 FL.S• 01"I S;a13Lt- For- G14Ak6iF� 0 2=c L t.3A( t- AA(A _-7y. cVRe-7.7 , I Kul. I IUIvyyUKr% I U tSt FtKI-UKMIrD: 0 til L `t J WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B1, B2, B3, B4 and B5 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2' ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE 5 SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e.AirSparae. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Boreholes to be completed grouted with neat cement _❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 15' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE Direct push borings CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify Regulations, ar Signed // Print Name Jog I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and apblll);able California laws. SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: Title/Company President / Brusca Associates, Inc. Date 3/27/17 DEPARTMENT USE ONLY DATE ISSUED FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE $ 125 x SR# RO # (3500) PR # (2900 C-57 VVC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 NZ000-0077 X7 J )-, WELL PERMIT APP