Laserfiche WebLink
pdUIN <br />n <br />SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />Evi <br />nronmental Health Department <br />SITE MITIGATION WELL & 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 construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address adjacent to 327 E. Park St. <br />Cross Street N. San Joaquin St. <br />Property Owner* City of Stockton ROW <br />Address 345 N. EI Dorado St. <br />c-57 Contractor Gregg Drilling LLC <br />Address 950 Howe Rd. <br />Consultant/Sub-Contractor ATC Group Services LLC dba Atlas Technical <br />Address 1117 Lone Palm Ave., Suite 201B <br />City/State/Zip Stockton, CA 95202 <br />APN <br />City/StatelZip Stockton, CA 95202 <br />License# 1044456 <br />City/State/Zip <br />License# <br />Martinez, CA 94553 <br />City/state/zip Modesto, CA 95351 <br />Phone <br />Phone <br />Phone 925-313-5800 <br />Phone 209-579-2221 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 11 O ft. ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 2 in. ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />[K SOIL BORING 3 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes C4 No Boring Dia; Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 110 ft. TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE U PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING ID CPT -4 C 3 SC pa rgw, GROUT SPECIFICATIONS neat cement <br />of c. +0 110 <br />OVA Y�„W wl� �• w� <br />DESTRUCTION WORK TO BE PERFOR ED: b�'o DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />(940 <br /># WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />Signed <br />Print Name <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Co <br />Date <br />i <br />Application Accepted By: <br />grout Inspection t�yivates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />wirAbn u000 <br />FA Name <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 04-0 <br />FA Address <br />h <br />FA# <br />FA PE <br />2q6V <br />WP Reviewed By <br />Work Plan Date <br />!.� 8 Z <br />❑ G57 �,G57 <br />Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ <br />Access Agreement OKLead Agency Approval <br />VMFR <br />COMMENTS/CONDITIONS: <br />LA �n1„-� d�� -�o 0 �` vJ�e L <br />N0 0 S r ac\W"A ka 1 a0V Q �, +1D <br />he o S p <br />✓ 13 "t <br />resp <br />WP TYPE <br />PE <br />SC <br />F E INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />Zq� <br />`3 <br />$152 x <br />13503 <br />p� <br />/u ZZ <br />A� <br />Vv <br />4-07 Site Mitigation Well Permit Application <br />