Laserfiche WebLink
SAN J OA Q U I N Environmental Health Department <br />COUNT y <br />SITE MITIGATION WELL Ot BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to conslruG and/or install the work descdbed. <br />This application is made in compliance With San Joaquin County Development Title, Chapter 9A 115.3, and the San Joaquin County Well Standards. <br />on Address <br />1904 <br />West Charter <br />Way <br />Clty/statelzip Stockton/CA/95206 <br />Phone (925) 278-8688 <br />cross street <br />Tillie <br />Lewis Drive <br />❑ <br />APN 163-02041 <br />DIA. OF BOREHOLE 4 inch <br />Property owner• Glenn Springs Holdings, Inc. Phone <br />(713)552-8785 <br />Address 5 Greenway Plaza, Suite 110 Citylstatelzip Houston/rX/77046 <br />C47 Contractor Confluence Environmental, Inc. License# 913194 Phone (707) <br />Address 6821 8th Street City]State/zip Rio Linda/CA/95673 <br />Consultanusub-contractor Geosyntec Consultants, Inc. License# Phone <br />Address 1340 Treat Boulevard, Suite 208 citylstatelzip Walnut Creek/CA/94597 <br />TYPE OF WELLIBORING <br />639-7709 <br />(925)278-8888 <br />'Note: Offstte BodngsNVells Require Access Agreements or Encroachment Pemrits <br />NUMBER <br />❑ MONITORING <br />❑ EXTRACTION IVaporAYaler) <br />❑ SOILVAPORPROBE <br />C9 SOILBORING <br />E3INJECTION IAk8;ww.0zanal <br />❑ OTHER _ <br />WEWSOIL BORING IDS $-1 <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ <br />HOLLOW STEM <br />BORING DEPTH 5.5 feet <br />❑ BOLTED TRAFFIC BOX ❑STOVEPIPE <br />❑ <br />HAMMER/DRIVEN <br />DIA. OF BOREHOLE 4 inch <br />❑ MULTIPLE CASINGS MULTILEVEL WELL CASING CIA <br />❑ <br />MUD ROTARY <br />CASING THICKNESS <br />TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />5 0 <br />PUSH POINT (GP/CPT) <br />CONDUCTOR CASING 01 Yes ❑No <br />Wine Dia: Casing Me: cesing Depth: <br />09 <br />HAND AUGER <br />GROUTSEALDEPTH <br />TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br />❑ <br />OTHER: <br />GROUT SEAL PUMPED? ❑ Yes ❑ No <br />(Note: Maxknum Freefall Depth Is 30 FI) <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: rCHECKALL THAT APPLVI <br />❑ OVER•BORE DIAMETER of _ Inches to depth of feel <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to _ feel below surface <br />Fiv�st��ov�soil bgrin�;; will eac�t be;�dv��fc d to 5.5 fede�el�Y��round surface to collect soil samples at <br />eac o e ortng oc Ions, as escrl e n ffte attache or n. <br />//���an Joaquin County Ordinance Codea and 3tendaMs, and all other applicable California laws. <br />Signed /./fin/./ Tifle/Company Senior Scientist/Geosyntec Consultants, II1C. <br />Print Name Ronald M. Gerstler Date August 12, 2022 <br />UCYHKIMCNI USC UNLY <br />Application Accepted By:����J� Date Issued: <br />Cy <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dales: <br />F cili /Site Information <br />FA Name <br />sleo og� <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.slcehd.com <br />EHD 29-01 04o"7 Site Minganonwdi Per"( <br />FA PE <br />24 Q <br />WP Revievred By <br />I <br />Work Plan Dale <br />Q Z C aZZ <br />❑G57 G57Aulhodza9w WrO9wIo Sign Permh <br />❑Workers Camp ❑ Workers Comp Waiver <br />❑EnaWment Permit ❑Access Agreement ad Agency Approval RMFR <br />COMMENTSICON DITIONS: <br />VIPTYPEI <br />PE <br />SfrC�, <br />FEE INFO <br />JAMT RENtiTTED1 <br />CHECK# <br />I RECV'D BY <br />I DATE <br />I WELL PERMIT# <br />INVOICE# <br />Permit <br />go <br />�t-��$1,°� <br />'2, <br />3 j G- <br />`Jq <br />916 <br />Appmceuon <br />