Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 Af D <br /> Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.s69ov.orglehd <br /> �/FOR <br /> WELL & BORING PERMIT APPLICATION JUL 2 6 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in copT�ACES <br /> Joaquin County Development Title,Chapter 9-1115 3 at�d thg Standards of the San Joaquin County Environmental Health Department. <br /> -Road(Highway 33 3 yel4b S. `quJ933 <br /> Site Location 9 y ) Cross Street Schaefer Road Cit, Vernalis Zip 95385 APN 255-180-07 <br /> Property Deana M.Noonan Trac <br /> Owner Address 34960 Highway 33 City y Zip 95304-9300 Phone (925)784-0080 <br /> C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite A City Woodland Lie 906899 Phone (530)661-3600 <br /> Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City Oakland Lic N/A Phone (510)466-7148 <br /> Billable Party SAIC(see above) Address <br /> City Zip Phone <br /> GIS Coordinates:X -121.290991 Y 37.634037 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> L]NEW WELL/BORING(CPT GEOPROB ,)­IYDROPUNCH,HAND-AUGER,OTHER) <br /> Lx]SOIL BORING IDs D,K <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: EISTEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE X PIPE <br /> _bd SOIL BORING LXj PUSH POINI&I GROUT SEAL PUMPED:❑Yes Lxl No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AfrSoarae,ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELLS)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and ail a b California laws. <br /> Signed Title/Company 44ao <br /> Print Name Date 2 1/ / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 2 <br /> WORK PLAN DATED Zp / <br /> APPLICATION ACCEPTED BO DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY l�C DATE IZ/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE IRO# INVOICE <br /> REQUEST PR# <br /> o J $122 x SR# 00631 <br /> RO# <br /> 3500 <br /> (7/0 FIR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 <br /> WELL PERMIT APP <br />