Laserfiche WebLink
AU'U 0 j 201SAN JOAQUIN COUNTY <br />z "r' NVIRONMENTAL HEALTH DEPARTMENT <br />NVIRONMENTAL HEU'N Hazelton Avenue, Stockton, CA 95205-6232 <br />•. P PEWAPMq$09) 468-3147 Fax: w <br />(209) 468-3433 Web: ww.siaov.org/ehd <br />LOP <br />SITE MITIGATION <br />UNIT IV <br />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 />Application is hereby made to San Joaquin County for a pennitto construct and/or Install the work tlescribed. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />Site Location 17100 Murphy Parkway <br />Property <br />Owner Buzz Oates <br />C-57 Contractor Cascade Drilling <br />Consultantl5ub Cntr Brosca Assoc., Inc <br />Billable Party Brusca Assoc., Inc. <br />GIS Coordinates: X 37.806 Y •12 <br />City/State Secramento/GAp 95814 Phone (9161379800 <br />CitylState West Sac., CA.ic 938110 Phone (916) 638-1169 <br />CitylState Roseville, CALic CEG#1948 Phone (916) 677.1470 <br />City <br />1.287 <br />Cross Street D'Arcy <br />Parkway <br />City/State Lathrop, CA <br />Zip 95330 APN 190-120-009 <br />Sq <br />_[OTHER: l Oaa Mamwedirc'xp w <br />❑ <br />OTHER: <br />APPROX. BORING <br />Address 655 Capitol Mall Suite 900 <br />Address 3000 Duluth Street <br />Address PO Box 332 <br />Address PO Box 332 <br />WELL 1[ <br />OTHER <br />OF WELLIBORING <br />❑ MONITORING <br />❑ EXTRACTION: Vapor/ Water <br />C1 SOIL VAPOR PROBE <br />❑ SOIL BORING <br />HYDROPUNCH, HAND -AUGER, OTHER) <br />iB HOLLOW STEM <br />❑ HAMMER/DRIVEN <br />❑ MUD ROTARY <br />❑ PUSH POINT (GP/ CPT) <br />lState Rosevllle, CAZIp 95661 Phone (916) 677-1470 <br />CONSTRUCTION 3PECIFICATION3 <br />DIA. OF BOREHOLE 8" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />DEPTH OF GROUT SEAL 2' TREMIE TYPE TO BE USED: El AUGERS 0 <br />HOSE ❑PIPE <br />OUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 3o Fr) <br />GROUTSPECIFICA <br />nnl9s neat Cement Grout <br />El <br />Ar sees. ozane <br />_❑ INJECTION ri.e m <br />l ❑HAND <br />AUGER <br />PE CODES <br />Sq <br />_[OTHER: l Oaa Mamwedirc'xp w <br />❑ <br />OTHER: <br />APPROX. BORING <br />BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br />CCDUCTOR CNo I7 Yes: Casin Die: Casing Depth: Boring Die:_ <br />COMMENTS: Gverdrlll damaged soil gas monitoring well SGMW1ONantl re rater <br />in bore ole rsame con�igura o� <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />1_# OF WE[ <br />OVER -BORE DIAMETER OF <br />WELL IDs: <br />GROUTSPEC <br />TREMIETYPE <br />COMMENTS <br />�_INCHES <br />TO DEPTH OF 1O FT <br />PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />EXPLOSIVES FROM TO FT BELOW SURFACE <br />MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />pplicable Californ <br />ia laws. <br />I,9I■fit <br />Title/Company President I Brusca Associates, <br />SITE MAP IN UNIT IV FILE -SITE ADDRESS <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTSlCONDITIONS: <br />DEPARTMENT USE ONLY <br />DATE ISSUED <br />FINAL INSPECTION BY <br />Inc. <br />AREA <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />REQUEST <br />RO # <br />PR# <br />INVOICE <br />$125 x <br />SR# <br />RO # <br />3500 <br />PR # <br />2900 <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 5199/12 WELL PERMITAPP <br />