Laserfiche WebLink
SAN JUAUUIN <br />Environmental Health Department <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 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 <br />816 W. Main Street City/State/Zip Ripon, CA 95366 Phone <br />Cross Street Vera Avenge APN 259-180-160 and -. Per M Aev SoWery g a�lioR <br />Property Owner* Bethany Home Society of San Joaquin Co. Inc. Phone 209 5994221 <br />Address 930 W. Main Street <br />C-57 Contractor None <br />Address <br />Consulta_ <br />Address 215 W. Dakota Avenue <br />City/State/Zip Ripon, CA 95366 <br />License# <br />City/State/Zip Clovis, CA 93612 <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 ee ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ EXTRACTION (VaporlWater) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE �❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum reejall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs — , -2, SV -3, SV -4 GROUT SPECIFICATIONS �, 4 a ('!y' 4 1D k) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <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: These will be temporary soil vapor probes that will be abandoned in 48 to 72 hours <br />ertify�at I am autho ized to <br />San/J�aquin County�rdinai <br />Signed ' <br />Print Name ichael <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilitv/Site Information <br />this application and that the work will be done in accordance with <br />and Standards, and all other applicable California laws. <br />Title/Company Krazan & Associates, Inc. <br />Date August 17, 2021 <br />FA Name <br />1868 E. Hazelton Avenue I Stockton, California 95205 � T 209 468-3420 I F 2060464-0138 <br />FA# <br />FA PE <br />WP Reviewed <br />By <br />�� <br />Work Plan <br />Date <br />��� <br />-57 <br />❑ C-57 Authorization <br />for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment <br />Permit ❑ <br />Access Agreement <br />❑ Lead Agency <br />Approval A plyFR <br />COM NTS/C <br />revp J� <br />NDITIONS. 50 <br />Ctiaw�d <br />V <br />"dr ori <br />vwyr o ✓erdr6 <br />I) <br />r G <br />X91, <br />ac <br />�1 <br />" <br />fo <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECKh <br />WCVvD BY <br />DATE <br />WELL <br />PERMIT# <br />INVOICE# <br />Permit <br />lDJ <br />313 <br />$152 x <br />'� Z' <br />'f2 414 <br />I www.sjgov.org/ehd <br />EHD 29-01 06-28-21 <br />Site Mitigation Well Permit Application <br />