Laserfiche WebLink
0 <br />0 <br />,,aP4 SAN JOAQUIN COUNTY <br />/2. <br />.—C� ENVIRONMENTAL HEALTH DEPARTMENT <br />1 '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*cehd.com <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 />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 6484 N Waverly Rd. Citylstateizip Linden, CA 95236 Phone 209-468-3066 <br />Cross Street Floor <br />APN 093-440-02 <br />Property Owner* San Joaquin County Public Works Dept. Solid Waste Phone <br />Address 1810 East Hazelton Ave. City/State/Zip Stockton, CA 95205 <br />C-57 Contractor Yellow Jacket Drilling License# 643081 Phone <br />Address <br />9460 Lucas Ranch Rd. city/state/zip Rancho Cucamonga, CA 91730 <br />Consultant CB&1 License# Phone (619) 279-4251 <br />Address 1042 Willow Creek Road Suite A101 PMB 512 City/State/Zip Prescott, AZ 86301 <br />209-468-3066 <br />(909)989-8563 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ❑ HOLLOW STEM BORING DEPTH 26V ❑ BOLTED TRAFFIC BOX ® STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) HAMMER/DRIVEN DIA. OF BOREHOLE 10° ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />EI SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS 2" Triple Nest TYPE OF CASING: ❑ STEEL I@ PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ISI No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Au Soarae. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE—ff HOSE -® PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) <br />WELD SOIL BORING IDs SG -11A GROUT SPECIFICATIONS Medium Bentonite Chips <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS 171 HOSE n PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of_ <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below <br />feet <br />I nereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San oaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed x Title/Company District Manager/ Yellow Jacket Drilling <br />Print Name Dean Coblish DateMarch 29, 2016 r, A <br />Application Accepted By: y// - <br />Grout Inspection By/Dates: 14 <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />-A,%u,ci ,—i✓i /.tL� r� Date Issued: L �,"�y 13 2nm <br />Sd Tas�V <br />A <br />z'--e9�-� .fes.-�. 5=�-d//d HFF^'h�o�,�cr,,.. <br />FA Name I <br />FA Address I <br />WP Reviewed By <br />TFA#T_PR# <br />I Work Plan Date F <br />FA PE I <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver <br />❑ Encroachment Permit ❑ Access Agreement [:)Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />G <br />SR TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />SERVICE REQUEST# <br />INVOICE# <br />Work Plan <br />1114/-7 f <br />300 <br />/ <br />l <br />'f 12 I <br />'e �b I X033 <br />Permit <br />$130 x <br />EHD 29-01 6-23-2015 <br />Site Mitigation Well Permit Application <br />