WP0043445 - Laserfiche WebLink

Home Browse Search

SAW] OAQUIN Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL ( 209 ) 953 =7697 For INSPECTIONS 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 San Joaquin County Well Standards . Job Address 1200 Humphreys Street ( see figures ) J City/State/Zip Stockton , CA 95203Phone 209-946-0246 Cross Street See figures APN 16203007 Property Owner* Port of Stockton Phone 209-946-0246 Address 2201 West Washington Street City/State/Zip Stockton , CA 95203 C -57 Contractor Penecore Drilling License# 906899 Phone 530-661 -3600 Address 220 N . East Street City/State/Zip Woodland CA , 95776 Consultant/Sub -Contractor Geosyntec Consultants License# N /A Phone 510-836-3034 Address 1111 Broadway 6th Floor City/State/Zip Oakland CA , 94607 175 - 303 " CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Approximately 7 ft ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA . OF BOREHOLE 3 . 7 inches ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth : ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED : ❑ AUGERS la HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes la No ( Note : Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs SS-817B -6A ; SS-817B-7A GROUT SPECIFICATIONS Type 1 /11 Portland Cement DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS . I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards , and all other applicable California laws . Signed i/' Title/Company Senior Geologist/ Geosyntec Consultants Print Name Kimberly Br ndt Date June 16 , 2022 MENT USE ONLY Application Accepted By : Date Issued : D Grout Inspection By/ Dates : r Destruction Inspection By/ Dates : Facilit /Site Information FA Namer� r FA Address O FA# kq !57030 PR# AA ''LWYa FA PE ya (6o WP Reviewed By Work Plan Date Z � ZZ ❑ C-5 C-57 7 Authorization for Other to Sign Permit ❑ Worker's Comp Els CoElWorker' mp Waiver Encroachment Permit ❑ Access Agreement ead Agency Approval R COMMENTS/CONDITIONS : WP TYPE PE ` SC FEE INFO AMT REMITTED CHaECK# RECV' D BY DATE WELL PERRMIT' #+ r � INVOICE# ( � $ 152 x � � (� ! Z �1! � ® 0 't? Permit Z1®✓ 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 -0138 1 WWW . Sjceh com EHD 29-01 04-04-07 Site Mitigation Well Permit Application