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WP0042621
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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SANTA FE
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23665
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2900 - Site Mitigation Program
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WP0042621
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Last modified
10/26/2022 1:54:45 PM
Creation date
10/26/2022 1:41:44 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
BILLING/PERMITS
RECORD_ID
WP0042621
PE
2902
FACILITY_ID
FA0025316
STREET_NUMBER
23665
Direction
S
STREET_NAME
SANTA FE
STREET_TYPE
RD
City
RIVERBANK
Zip
95367-
APN
24907009
ENTERED_DATE
10/7/2021 12:00:00 AM
SITE_LOCATION
23665 S SANTA FE RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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Tags
EHD - Public
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SAN J����:��!���1 <br />r, � t\I I T <br />J J � <br />SITE 6lIJu`u��C���f;\`u�n�GJV�1��1� : ��ir��G��6;9�� G�G6��G�(d�ru �E�6��u�='>!�`u�O�J��� <br />dor Wells ar�d �olriy�g� Use�l �®u• �ohi:�llmirl�l��L Vti�v���ig�iior7� arld �:emedia�cion <br />NON-REFUNDABLE PERMIT EXPIRES �I YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install tate work described. <br />Tltis application is rnad© in compliance with San Joaquin County Development Title, Chapter 9-1715.3, and the San Joaquin County Well Standards. <br />Job Address 23665 Soutlt Santa Fe Road <br />Cross Street Henty Road <br />Property Owner= <br />Address <br />Efren Martine? <br />2516 Acat�ulco WaV- <br />L-57 Contractor V&W Drilling <br />Address 1133 81ac1<hurst Drive <br />Consultant/Sub-Contractor Condor Earih <br />Address 138 Franl< West Circle, Suite I <br />CitylStatelZip P.iverbanldCA/953�7 <br />APN 249-070-090 <br />License# C57 #/720904 <br />City/State2ip <br />License# <br />Galt/CA/95632 <br />PG #16795 <br />City/5tate2ip Stockton/CA/95206 <br />Phone (209) 550-1154 <br />Phone <br />Phone <br />Phone 1209) 743-7743 <br />CONSTRUCTION WORIt TO BE PERFORMED: Note: Offsite BoringslWells Require Access Agreernenls or Encroachment Perntits <br />TYPE OF LVEWBOP,IPJG NUt.98EP. <br />❑ h10NITORIPlG ❑ <br />❑ EXTRACTION (VaporNVale�) ❑ <br />❑ SOIL VAPOR PROBE ❑ <br />❑ SOIL BORING ❑ <br />❑ INJECTION (AirSnamc Ornnrl ❑ <br />❑ OTHER ❑ <br />WELU SOIL 80RING IDs <br />INSTALLATION TYPE COtJSTRUCTIOtJ SPECIFICATIOPIS <br />HOLLO�P! STEt.1 BORIt.� DEPTH ❑BOLTED TRAFFIC 60X ❑STOVE PIPE <br />HAPAh1ER/DRNE1�1 DIA OF BOREHULI= ❑ h1ULTIPLE C.A5INGS ❑ F.1ULT1-LEVEL VrELL CASING DIA <br />FdUD ROTARY CASING THICKNESS _ TYPE OF CASING ❑STEEL ❑PVC ❑OTHER <br />PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes ❑Flo [3orirtg Dia' Casing Dia: Casing Depth <br />HAttD AUGER GROUT SEAL DEPTH TREFAIE TYPE TO 8E USED ❑ A.UGERS ❑HOSE ❑PIPE <br />OTHER. GROUT SEAL PUtAPED� ❑Yes ❑ No (Note. F/aximum FreefUl Depth is'�J Flj <br />GROUT SPECIFICATIOt•1S <br />DESTRUCTION WORK TO BE PERFORMED: <br />#14VELLS TO BE DESTROYED 'I <br />WELL IDs tv1W-9 <br />GP,OUT SPECIFICATIONS IJeat Cement <br />TREMIE T`!PE TO BE USED ❑AUGERS ❑HOSE � PIPE <br />COMMENTS; Explosives will be placed belovr the sanitary seal to depth. <br />Signed <br />DES I P.UCTION 141ETHOD: (CHECf< ALL THAT APPLYI <br />❑OVER -BORE DIAMETER of inches to depth of r_ feel <br />❑ PRESSURE GP,OUT To depth of Leet belovr surlace <br />❑ EXPLOSIVES From 26 to d0 feet belovr surface <br />❑ PAUSHROOM CAP ❑ 3 feel belovr surface or feet below surface if >3 feet <br />hereby certify that I am autftorized to complete this application and that the �vorl< will be done itt accordance with <br />n Joaquin County Ordihance Codes and Standa <br />__- ����—� Title; <br />Print Name � t.�-�:�-� ��� l Z _� Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />�-- — -- <br />DEPARTl9ENTUSE ONLY <br />Date Issued: I D �� �� <br />FA tJame <br />I�,ryu 11 ,r� � �q <br />FA Address <br />2,3 � <br />� <br />5���� �Q <br />FAiI <br />� � � � � <br />PR/1 <br />I� ��sz <br />FA PE <br />Z�' � � <br />lNP Revie�:�ed By <br />�� <br />Work Plan Date <br />❑ C-57 � •57 Aulhenza6on torOther to Sign Permit <br />❑ Wctkers Comp ❑ Wcrker s <br />Comp <br />Waiver ❑ Encroschmenl <br />Pc-rrrit <br />[� Access Agreen�nl Lead Agency <br />Approvd C}.MFR <br />C01�7117ENTS/CONDITIONS: <br />LVP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT RENlITT6D <br />CHECK# <br />RECV'�D� t3Y <br />DATE <br />WELL(,�P.E7F:6�71T# <br />INVOICE#1 <br />Permit <br />`��Z <br />3 �� <br />$152 x <br />j �j <br />j <br />� <br />i"� <br />Z� <br />� �) <br />Vv �tJa t W� <br />1P6S E. Hazelton Avetlue � Stcrckion, Cali�ornia 95205 � I 209 4G8�-3-120 � F 7_09 �;G4-0130 � �A�/vti:v.sjcehd.corn <br />Elis 24-0r o8-nt-17 site hliri�atinn'fJetl Permi[ App&catioh <br />
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