SR0083983 (3) - Laserfiche WebLink

Home Browse Search

>o..p4r.Fe SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N: < yllx 1868 Hazelton Avenue, Stockton, CA 95205-6232 1 k bYi Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 2045-Wc-Hazeit0TTSAve 5bl s Urxtwa- Aoe- City/State/Zip Stockton, CA 95203 Phone 209-946-0246 Cross Street S. Ventura Ave APN 145-080-02 - Property Owner` ,fsorae.WeiRbeFeer Qf4p./p r`P Am per Tr _ Phone 209-639-1211 Address 40 Be Brave Ave H24d ri`9'^"` f �`"% ai.o� City/StatelZip Saa-FFeeeisco, CA 2444' SFO 7 C-57 Contractor Cascade Drilling License# 938110 Phone 916-638-1169 Address 3000 Duluth St CitylState/Zip Sacramento, CA 95691 ConsultanUSub-Contractor CH21M License# N/A Phone 510-587-7557 Address 155 Grand Ave Suite 800 City/State/Zip Oakland, CA 94612 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6 ft bgs ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 4" ❑ MULTIPLE CASINGS ❑ MULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER IN SOILBORING 21 ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ONO Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air sexrue. ozonel ❑O HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs 3K and 4K(eighI borings In each GROUT SPECIFICATIONS Neat Cement will be poured into the hole once soil samples have been Collected. sampling area); see comments DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below sudace TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feel below surface if >3 feet COMMENTS: KP16-01 through KP16-05. 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 Title/Company Geologist / CH2M Print Name Jenny Salinas /- Date 7/29/2016 ,,/S �L DEPARTMENT USE ONLY �7/4!!/ Application Accepted By: --�-,�`� _ , "i Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name gpe 'T' jkf FA Address 2025 Id, A ZeI & 41fle 1 FM I cl)OQ 2PR# I O p 6 el FA PE wrWP Reviewed By I I Work Pian Date `z.c.c Zo ( jo ❑ C-57 C-57 Authodzatlan for Other to Sign Permit BorNorkersComp ❑ Workers Comp Waiver ;lLacroachment Permit 0-Kccess Agreement Eiread Agency Approval 1110wr COMMENTS/CONDITIONS: elf /nu- pc4f%n ��l/+r7n�1 wVt��G✓ f/ka`/ ese 4{�f ilecfo db/rfyer .7 >-rerf e4-440 6c e&*t geQ1✓L fv /, SR TYPE PE SC FEE INFO AMT REMirrEDI CHECK# I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Work Plan p Permit ''ZV5 3l3 $130x ?J `Y% Q/q7 g" s' ad 7550 / SSA EHD 29-01 6-23-2015 Site Mitigation Well Permit Application