Laserfiche WebLink
SANJOAQUIN p <br /> Q 1. � Environmental Health De artmenI <br /> CIt ; � —COUNTY <br /> Greotness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> 48 Hours Advance Notice Required For All 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 3081 North Tracy Boulevard City/State/Zip Tracy/ CA / 95376Phone ( 415 ) 617-5791 <br /> crossstreet West Clover Road APN <br /> Property Owner* T__; = m__ _'- _ Tr& CA/ Ca4,r ROB Phone (415 ) 617-5791 <br /> Address City/State0p Stockton/ CA / 95219 1 <br /> C-57Contractor EnProbe Environmental Drilling Services License# 1012248 Phone Sao- b9.? 2-1q <br /> Address P . O . Box 6093 city/stateizip Oroyille / CA / 95966 <br /> ConsultantISub-Contractor Partner Engineering and science, inc.Lieense# Phone (661 ) 316-8237 <br /> Address 2154 Torrance Boulevard city/statelzip Torrance / CA / 90501 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 51 IH BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor(Water) ❑ RAMMERIDRIVEN DIA.OF BOREHOLE 2 - 25° ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA <br /> IL4 SOILVAPORPROBE 2❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING []Yes WNo Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTIONtAksexrae.Ozanel ❑ HANDAUGER GROUTSEALDEPTH THEME TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes [I No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELVSOILBORINGIOS G(T40 anA 5(;41 GROUT SPECIFICATIONS Neat Cement <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 ❑PRESSUREGROUT To depth of feet belowsuriace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS ❑ HOSE El PIPE [I MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feel <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with I <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project teenager / Partner engineering and Science, Inc. <br /> Nolt Print Name Daniel Monteverde Date May 15 , 2020 <br /> q,pPt+y� DEPARTMENT USE ONLY <br /> 01A Application Accepted By: Date Issued: <br /> y�Grout Inspection By/Dates: v. I o 0,'%- 1 <br /> h� Destruction Inspection BylDates: <br /> Pry Facility/Site let matlon I � <br /> VI M FANam Q�e rt ' FAAddress y�8 ( N , ��� FA# oo Zg1`Y PR# O7T 1 21 <br /> •C FA PE Z61 WP Reviewed By Work Plan Dale Z/-7-17o(r/ <br /> ❑C57 0C57AVthor'vadon for Other to Sign Permit ❑Workers Gomp ❑Workers Comp Waiver ❑Encmachmenl Permit ❑Access Agreement ❑Lead AgenxyApproval ❑MFR <br /> COMMENTS/CONDITION•• S.+ i�' A�' rCS 4t'rJ .}{.• &HP �!r M-k w++1w -s <br /> i FC-KWY.1' �'p'10.Cl+-iN e, I`a.0 r-�' ��S t.il'+1'j /T wjM!-�F� t/!1 1( iaC b f IQrel *t <br /> Or rCeA <br /> GKY►1tv�il— re� �� 'uiHtc �vtr <br /> WP TYPE I PE I SC FEE INFO JAMT REMITTE CHECK# I RECV'D BY EDATE WELL PERMIT# INVOICE# <br /> Permit 121011 7\ $152 x 7— �p .UO Cat, - . v3 . La <br /> 1868 E. Hazelton Avenue I Stockton, �)fornia 95 205 ( T 209 468-3420 ( F 209 46 - sj ehdxom <br /> EHD2e-010601A7 � ! Site Mitigation Well Permit Application <br />