Laserfiche WebLink
SANAAQUIN --COUNT Y <br />Environmental Health DRaknent ev ED <br />Greatness grows here <br />SITE MITIGATION WELL & BORING PERMIT APPLICATI 2018 <br />ON/NotafEN <br />For Wells and Borings Used for Contaminant Investigations and RemediatidOW/s4 HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CES <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 />Job Address street in front of 640 N San Joaquin St. City/State/Zip Stockton, CA 95202 Phone <br />Cross Street Park St. APN <br /> <br />Property Owner* City of Stockton (ROVV) <br /> <br />Phone <br /> <br />MAY 2 5 <br />Address 345 N. El Dorado St. City/State/Zip Stockton, CA 95202 <br />License# 485165 <br />Phone 925-313-5800 C-57 Contractor Gregg Drilling & Testing <br />Address 950 Howe Rd City/State/Zip <br />License# <br />Martinez, CA 94533 <br /> <br />Consultant/Sub-Contractor ATC Group Services, LLC <br /> <br />Phone 209-579-2221 <br />Address 1117 Lone Palm Avenue, Suite 201B City/State/Zip Modesto, CA 95351 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />o MONITORING 0 <br />0 EXTRACTION (Vapor/Water) 0 <br />O SOIL VAPOR PROBE 0 <br />SOIL BORING 2 El <br />0 INJECTION (Air Sperm Ozonel 0 <br />0 OTHER 0 <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 55-75 <br />HAMMER/DRIVEN DIA. OF BOREHOLE 2in. <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No <br />HAND AUGER GROUT SEAL DEPTH 75 ft. max <br />OTHER: GROUT SEAL PUMPED? D Yes tia No <br />BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS EJ HOSE 121 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs HP-10 & HP-11 GROUT SPECIFICATIONS neat cement grout <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS ID HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />LI OVER-BORE DIAMETER of inches to depth of feet <br />D PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />D MUSHROOM CAP 0 3feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />Signed <br />Print Name <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company I c't Ortg y1/-1‘,/c_iik C, 6 <br />z(--1 52,v-t) 02.S. <br /> <br />DEPARTMENT USE ONLY <br /> <br />/30/4 <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />li-ff <br /> <br />FA Name 1— T ,,,__ <br />FA Address (4, 10 t.1 . 1-( 4"-e--- -C4- 0 .0-1110 0 i 3 <br /> FA# 0 02—W1 1 PR# <br />FA PE ,)-91, ( a a y WP Reviewed By L -)( , Work Plan Date <br />3/1 itAi <br />0 C-57 LKC-57 Authorization for Other to Sign Permit Er<rker s Comp El Workers Comp Waiver REncroachment Permit 0 Access Agreement atead Agency Approval givIFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ?"‘31 ":. 3 l 1 $152x "2- .. 4. ,l'l 1 A 1/3.0/iX tAlP003\47 1 -- <br />'14 186 i-laLlt Avenue Stockton, California 952051 t 209 48-342 9 464-0138I www.sjcehd.com <br />Site Mitigation Well Permit Application <br />Date <br />EHD 29-01 08-01-17