SR0070719 - Laserfiche WebLink

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o"qu�� SAN JOAQUIN COUNTY nECE1AL ENVIRONMENTAL HEALTH DEPARTMENTLOP W. •: `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 OCT 0 3 20 1iITE UNIT MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sIljov,orgi/ehh � � rel=E�t;� r( WELL & BORING PERMIT APPLICA �iT�SEuICES 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 1501 D'Arcy Pkwy Cross Street Howland City/State Lathrop, CA Zip 95330 APN 198-13-032 Propert Owner �ichland Crossroads L.P. Address 3000 Lava Ridge Court, Suite 115 City/State Roseville, Ca Zip 95661 Phone (916)782-3330 C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez, CA Lie 485165 Phone (925) 313-5800 Consultant/Sub Cntr HydroFocus, Inc. Address 2827 Spafford Street City/State Davis, CA Lic Phone (530) 759-2484 Billable Party HydroFocus, Inc. Address P.O. Box 2401 City/State Davis, CA Zip 95617 Phone (530)759-2484 GIS Coordinates: X 37.80041 Y -121.28369 CONSTRUCTION WUKK TO BE PERFORMED: ❑0 NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDS ❑■ WELL IDsKMW-8 ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I 0 MONITORING 9 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 0 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 ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS neat cement ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 30 ❑ BOLTED TRAFFIC BOX OR 9 STOVE PIPE CONDUCTOR CASING N No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: See location map & proposed construction in workplan NOTE: OFFSITE WELLS 8t BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 4 # OF WELL(S) TO BE DESTROYED XOVER-BORE DIAMETER OF 701&8(2"1 INCHES TO DEPTH OF 15, 20, 25 FT WELL IDs: PZ -1, PZ -2. PZ -3, PZ -4 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑■ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS See location map and well permits in workplan 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 =1: SignedLA� Title/Company Assistant Hydrologist/HydroFocus, Inc. Print Name Christina Lucero Date 10 2 SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED !►uG uiT 9,-2 APPLICATION ACCEPTED BY J, 16A GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DEPARTMENT USE ONLY of 1) `19R."y oe W'I q , 4 f9 rmeo P DATE FINAL INSPECTION BY DATE EAA IGo1 - TE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # PR # INVOICE �1REQUEST OcCi� $130, j0 S /� ^ SR# 7v/Zo (35F00)7072-/ 2 o O(2900)' v S 4 C-57WC ✓ WAIVER � C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT s� ENCROACHMENT DOC /Niv EHD 29-01 7/ 4/14 WELL PERMIT APP