Laserfiche WebLink
TYPE OF WELL/BORING <br />in MONITORING <br />0 EXTRACTION (Vapor/Water) <br />0 SOIL VAPOR PROBE <br />0 SOIL BORING <br />1:1 INJECTION (Air Spam. Ozone) <br />ID OTHER <br />NUMBER INSTALLATION TYPE <br />1 „lEr HOLLOW STEM <br /> CI HAMMER/DRIVEN <br /> El MUD ROTARY <br /> o PUSH POINT (GP/ CPT) <br />-HAND AUGER <br />o OTHER: <br />WELL/ SOIL BORING IDs kAN-5 <br />I hereby certify that lam authorized to complete this application and that the work will be done in accordance with <br />San J9etriuin unty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company STAFF GEOLOGIST / AGE <br />Date 1/17/19 Rine M. Toth <br />S A 7-\ . NJOAQUIN .<, COUNTY- <br />Greatness grows here. <br />Environmental Health Department <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 />Job Address 1120 North Holly Drive City/State/Zip Tracy, California 95304 Phone (209) 467-1006 <br />Cross Street East 11th Street APN 233-369-19 <br />Phone (209) 467-1006 Property Owner* Levand Family Trust/ Levand Bright Family Trust - Trustees, Paula Levand & John Konkel <br />Address 24692 Sand Wedge Lane City/State/Zip Valencia, California <br />(209) 467-1006 C-57 Contractor Slagle Drilling Corporation License# 1046151 Phone <br />Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA <br />(209) 467-1006 Consultant/Sub-Contractor AGE License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 20' 1:1 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 8.25" 12 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL El PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes El No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 1.5' TREMIE TYPE TO BE USED: 0 AUGERS CI HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes CiONo (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: — See attached Work Plan and site plan — <br />Signed <br />Print Name <br />DEPA MENT USE ONLY <br />Application Accepted By: Date Issued: 1 24 1, 1,61 <br />Grout Inspection By/Dates: M <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name 5 - eme141 Legain4 g r wi FA Address 4. 3 fe..3 fi <br />+— c7sIt M t 1 FN/et.) 2.3ctil PR# <br />FA PE 7)1/(0 t) WP Reviewed By L.,)( Work Plan Date 7-7.,1312...o/e,,- <br />Agency Approval Dian 0 C-57 Iii4 Authorization for Other to Sign Permit ErCer's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 13.tts <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit Vito 1 -5 15 $152x ,We 1 (5-2, 713145 L./.5‹ % 1 tot 6 v., F0,3312,31 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application