WORK PLANS - Laserfiche WebLink

Home Browse Search

oPqul,y .c SAN JOAQUIN COUNTY 2 —r� ENVIRONMENTAL HEALTH DEPARTMENT •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 �q•-:',,;:•�j�P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*cehd.com <<Foa 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 10101ndustrial Drive City/State/Zip Stockton,CA 95206 Phone Cross Street South Airport way APN 177-260-530-000 Phone 510-352 Address M3 WhMvenue City/State/Zip• . C-57 Contractor Confluence Technical Services,Inc License# 1035255 Ph 5 707-639-7709 one Address 6821 6th Street City/State/Zip Rio Linda,CA 95673 Cons ultarlb-Contractor Terraphase Engineering Inc License# Phone 610-955-2248 Address 1300 Clay St,Ste 1000 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 1 ® HOLLOW STEM BORING DEPTH 30.5 ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 2-in diameter TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaree.Ozone) ® HAND AUGER GROUT SEAL DEPTH 16 ft TREMIE 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 MW-04 GROUT SPECIFICATIONS Portland Type IAI 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 []PPE ❑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 Title/Company Sr Project Geologist,Terraphase Engineering Print Name Molly Coates Date 1/28126 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Z l I L!v Grout Inspection By/Dates: 2 Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address L.wC IFA# I PR# Ip� c, FA PE WP Reviewed By Work Plan Date ❑C-57 -57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver•-dEncroachment Permit ❑Access Agreement Epad Agency Approval MFIR COMMENTS/CONDITIONS: k0b p i L W I��y�• SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# vvb,I�rarr 0' 113 .� l ' �' 3 t 314"WPa(901421 Pe L- 1 121 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application