FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

of,•.°"t" SAN JOAQUIN COUNTY ....,• c Wli z• t -I ENVIRONMENTAL HEALTH DEPARTMENT LOP :`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �' - �,'P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si4ov.orq/ehd UNIT 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 34701 S.Welty Road Cross Street Highway 33 City/State Vemalis Zip 95385 APN 255-180-15 Property Owner Kamail Sandhu Address 3972 W Durham Ferry Road City/Slate Tracy Zip 95304 Phone (209)612-1127 C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite A City/State Woodland Lic 906899 Phone (530)661-3600 Consultant/Sub Cntr.SAIC Address 1000 Broadway,Suite 675 City/Slate Oakland Lic N/A Phone (510)466-7148 Billable Party SAIC(see above) Address City/State Zip Phone GIS Coordinates:X -121.29056 Y 37.63480 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT EOPROB YDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SB-4.SB-5.&SB-6 ❑WELL IDs „[ ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: []STEEL ❑PVC ❑ OTHER C _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: O AUGERS ❑HOSE El PIPE .q_[0 SOIL BORING Q PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface f _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: L COMMENTS:Fieldwork is on behalf of Chevron. Site name: Ahern Road-Vernalis(SJCEHD reference address=35500 Welty Road) 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 L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applica e Californiaal/��ifjlaws. //�� /`� /� Signed �_ _le�L� Title/Company I`�J�Ct lrr°o1• i3l A_TC Print Name SLa�1 GL��kC Date r j6�1 z DEPARTMENT USE ONLY ? SITE MAP IN UNIT IV FILE-SITE ADDRESS J553o061_T' WORK PLAN DATED 106 r << / APPLICATION ACCEPTED BY J. DATE IS _/69 Of GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE f� REQUEST I PR# /� 1 U� $125x I 12s cl T_ 8-/0-/2 SR# (oSY4 Cl Po 3 7 7 s 00 PR# 2900) C-57 WC - WAIVER_tY✓� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k- ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP