Laserfiche WebLink
P.to..m . )4- 2_ <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />--COUNTY <br />Grecilness gt-ovy <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Rennediation <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 .),‘ L). Pt cc G- 3ku-15-- city/State/Zip Loa,..,. eis,. . Phone <br />i <br />Cross Street eitp54u-- P4) Cz. APN <br />Property Owner' VIA] C. Sir(2.e..4" Vipsit.4-mpts U—C., Phone <br />City/State/Zip 1.6.;,CIL45.4 2.10 <br />License# 1 eItfUe2)0t S Phone <br />City/State/Zip ep54- N D Apo e A. (343-03 <br />I <br />Consultant/Sub-Contractor License# Phone <br />Address ..t1.• QINP— &(-. 2412 1+ <br />C-57 Contractor 14Abr rgA kACOs LLe <br />Address /..k hilkOrIV SJ I <br />7zgt_Sklftgu. <br />65o -3z6 <br />Address City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: •Note. Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELIJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM BORING DEPTH U BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (VaporWater) 11 HAMMER/DRIVEN CIA. OF BOREHOLE D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE ID MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 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 />INJECTION (Air Soarqe, Ozcnei 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYEEA— Si/ 6 Wills D OVER-BORE DIAMETER of II inches to depth of 13-46 feet <br />WELL IDs S V et -0.5 El PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS fli Asoi eikirkw4 efoard El EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED AUGERS 0 HOSE 0 PIPE El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: Gv E., —0 kriNttuilL, L—A-01 %WA VO 7s-1, / 4 ( --4‘, tw.AA 4-c) kits c---- <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed C••••,... .---' c2, <br />. <br /> Title/Company 1r na vniAlk . OcklY y -Lk rultel L.,t_ e _ I <br />Print Name Ipyr tf\ Illtime.kiAl Date WI Ojak 2..‘ 20 "Z• t <br />1 <br />DEPARTMENT USE ONLY <br />Application Accepted By: JEFFREY WONG Date Issued: 3/29/2021 <br /> <br />Grout Inspection By/Dates: <br /> <br />202i Destruction Inspection By/Dates: <br /> <br />Facility/Site Information <br /> <br />FA Name CITY LODI CENTRAL PLUMEFAAddress 221 W. PINE, LODI FA # FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By J \N Work Plan Date 3/4/2021 <br />14 C-57 11 C.57 Authorization for Other to Sign Permit CI Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit til Access Agreement q Lead Agency Approval MIER <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />TOTAL 2 WELLS TO BE DESTROYED <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 313 S152 x 2 304 113775 J : 3/16/2021 WP0041873 <br />1868 E. Hazelton Avenue l Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sicehd.com <br />EHD 29-01 08-01-17 SR0083463 Site Mitigation Well Permit Application