SR0070719 - Laserfiche WebLink

Home Browse Search

RECEIVED SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OCT 03 Q�4 Y E MITIGATION '. 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: OMMkOAMMUt HEAD 17 WELL & BORING PERMIT APPLICATIOV"'T/SERVICES 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 County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 17681 Howland PropertyY Owner Ealy of Lathrop Cross Street D'Arcy Pkwy Address 390 Towne Centre Drive C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road Consultant/Sub Cntr HydroFocus, Inc. Billable Party HydroFocus, Inc. Address 2827 Spafford Street Address P.O. Box 2401 GIS Coordinates: X 37.80081 Y -121.27742 moi. C>y I -12f,2 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs City/State Lathrop, CA Zip 95330 APN 198-01-032 City/State Lathrop, Ca Zip 95330 Phone (209) 941-7430 City/State Martinez, CA Lie 485165 Phone (925) 313-5800 City/State Davis, CA Lie Phone (530) 759-2484 City/State Davis, Ca Zip 95617 Phone (530) 759-2484 ❑f WELL IDs KMW-9 AID # FAC # ❑ OTHER IDs FEE INFO AMT REMITTED TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑� MONITORING I] HOLLOW STEM DIA. OF BOREHOLE 8 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 4 _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL ❑p PVC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 10 TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes @9 No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION (i.e.AirSoaroe.Ozone) ❑HAND AUGER GROUT SPECIFICATIONS neatcerrent ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 30 X BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING 9 No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: See location map 8 proposed construction in NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) 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 and all applicable Califo is laws. Signed �^ "„� = Title/Company Assistant Hydrologist/HydroFocus, Inc. Print Name Christina Lucero Date w o L I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS ii &z,C j 'lQKw4l r L i�Tl�4oP WORK PLAN DATED Ila Grc-U 5 20 2a 7V APPLICATION ACCEPTED BY J • a D /9,<,t ;I DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: FINAL INSPECTION BY DATE DEA �6 DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE )tj!Q2 $130x d -caut-Q to -311,/ SR# 7h7 iit 2io 390 3 °0 2d(, 0 S3� SG 3 is C -57 y WC 6� WAIVER _Wir} C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP