SR0071683 - Laserfiche WebLink

Home Browse Search

O.P4utk' •CSAN JOAQUIN COUNTY ).• ....mit •.OG 2 ENVIRONMENTAL HEALTH DEPARTMENT Q: a NI Vu■ � 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.si9ov.org/ehd/ehd 9�/FORS ORIGINAL LOP SITE MITIGATION UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Count Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Y700 South Health Department. _❑ EXTRACTION: Vapor/ Water EI Dorado Site Location Cross Street East 3rd Street city Stockton Zip 95206 APN 167-033-26 Property San Jpac�uin Housing Investment Owner Group LLC Address 1209 East 8th Street City Stockton Zip 95206 Phone 209-937-7625 C-57 ContractorAdvanced GeoEnvironmentaAddress 837 Shaw Road City Stockton Lic 680227 Phone209-467-1006 Consultant/Sub &Vanced GeoEnvironmen%dress 837 Shaw Road City Stockton Lic 680227 Phone 209-467-1006 Billable Party Advanced GeoEnvironmental Address 837 Shaw Road City Stockton Zip 680227 Phone 209-467-1006 GIS Coordinates: X51--' � 3q 87Y —[2-1. �EIS CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs SV1, SV2, SV3, SV4 ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE ❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN 4 X] SOIL VAPOR PROBE ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i e Air Sparge. Ozone) ❑ HAND AUGER _❑ OTHER: COMMENTS: CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 1.25 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER DEPTH OF GROUT SEAL up t0 10' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED: ❑ Yes L4 No (MAXIMUM FREE FALL DEPTH IS 30 FT) GROUT SPECIFICATIONS Type 1/II, neat cement ❑ OTHER: APPROX. BORING DEPTH Up t0 10' ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELLS) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, an5,#WapPI!Pble California laws_ Signed _ Print Name SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED M ✓ lze H APPLICATION ACCEPTED BY . ( _ N ,b GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: Title/Company President, Advanced GeoEnvironmental 'ARTMENT USE ONLY Et.. DcAe19DO 51 DATE FINAL INSPECTION BY 02/24/2015 ,TE ACCOUNTING ONLY: AID # FAC # PE CODES % I INFO - MT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PIR # INVOICE o $ ( 126 SR# 7� RO # 3500 PR # 2900 C-57 r WC V WAIVER Y1—C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC lVtg EHD 29-01 07/28/10 WELL PERMIT APP