Laserfiche WebLink
Job Address 47 East 11th Street <br />Cross Street North El Portal Avenue <br />City/State/Zip Tracy, CA, 95376 Phone (661) 904-2133 <br /> <br />APN 233-369-14 <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: loOth,(4.1- oeittAk <br />Facility/Site Information <br />:retipo <br />3--(44 o0- <br />DEPARTMENT USE ONLY <br />Date Issued: I /aet I? <br />FA Name FA Address <br />FA PE WP Reviewed By <br />'K ?-c teAteiti-h FA# 00235ff) <br />Work Plan Date <br />PR# o514-1 61- <br />CI C-57 Xp-57 Authorization for Other to Sign Permit CI Worker's Comp CI Worker's Comp Waiver El Encroachment Permit CI Access Agreement CI Lead Agency Approval CI MFR <br />COMMENTS/OONDITIONS: <br />AMT REMITTED <br />(7 0 <br />CHECK# <br />7,61 ?Jo <br />RECV'D BY WELL PERMIT# <br />P 0 o3 <br />INVOICE# WP TYPE <br />Permit 0902, 313 <br />PE <br /> SC <br />$152x 5 <br />FEE INFO DATE <br />SANs,JOAQUIN <br /> <br />Environmental Health Department <br />NJ T y <br />SITE MITIGATION 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 />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Property Owner* Levand Family Trust - Paula Levand-trustee Phone (661) 904-2133 <br /> <br />Address 24692 Sand Wedge Lane City/State/Zip Valencia, CA 91355 <br />C-57 Contractor <br /> Slagle Drilling Corporation <br />Address 11345 Trade Center Drive <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Inc. <br />Address 837 North Shaw Road <br />License# 1046151 <br />Phone 916-363-9355 <br />City/State/Zip Rancho Cordova, CA 95742 <br />License# 680227 Phone 800-511-9300 <br />City/State/Zip Stockton CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />El MONITORING 0 HOLLOW STEM BORING DEPTH <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE <br />CI SOIL VAPOR PROBE CI MUD ROTARY CASING THICKNESS <br />l BOLTED TRAFFIC BOX I=1 STOVE PIPE <br />l MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL 0 PVC El OTHER <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />CI INJECTION (Air Sparqe, Ozone) 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: CI AUGERS 0 HOSE CI PIPE <br />CI OTHER I=1 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 5 [g] OVER-BORE <br />El PRESSURE GROUT <br />['EXPLOSIVES <br />ID MUSHROOM CAP <br />DIAMETER of 8.25 inches to depth of 21 & 45 feet <br />To depth of feet below surface <br />From to feet below surface <br />3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />WELL IDs MW3, MVV7, MW8, MW9, MW10 <br />GROUT SPECIFICATIONS Portland Type ll (94Ib +5.5-6 ga)lons) <br />TREMIE TYPE TO BE USED ID AUGERS l=1 HOSE l=1 PIPE <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joacpn County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company PROJECT GEOLOGIST / AGE <br />Date 11 JULY 2019 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Signed <br />Print Name <br /> BRIAN MILLMAN