Laserfiche WebLink
SAN.dOAQUIN Environmental Health Department <br /> 11'mJ' —COUNTY— <br /> GL "' Greatness 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 <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 30707 Corral Hollow Rd. city/state/zip Tracy/CA/95377 Phone 916-548-2503 <br /> Cross Street Tracy Hills Dr. APN 253-030-150-000 <br /> Property Owner- Tracy Parcel Three, LLC Phone 916-548-2503 <br /> Address 2033 N Main St #309 city/statelzip Sacramento/CA/95826 <br /> C57contractor PeneCore Drilling, Inc License# 906899 Phone 530-661-3600 <br /> Address 220 N Fact S{ cilylstate/zip Woodland/CA/95776 <br /> ConsultanUSub-Contractor Haley &Aldrich, Inc. License# Phone 714-371-1805 <br /> Address 2033 N. Main St. #309 cltylstate/zip Walnut Creek/CA/94596 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Ogsite BoringsAVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORINGDEPTH — ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaponWaler) ❑ HAMMERIDRNEN DIAOFBOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING OW <br /> 00 SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL[I PVC❑ OTHER <br /> ® SOIL BORING 4 ® PUSH POINT(GP/GPT( CONDUCTOR CASING ❑Yes❑No Boring Me: Casing as: Casing Depth: <br /> ❑ INJECTION Wr Soxoe.aeonet 50 HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (No(e:Ma)dnm Freetal Depth is 30 Ft) <br /> WELU SOIL BORING IDs SGP-Olthrough SGP-O5 GROUTSPEGRCATIONS <br /> SB-01 through SS-04 <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 ❑PRESSUREGRWT To depth of feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [:]HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ;;` �� Title/Company Senior Geologist/Haley &Aldrich, Inc. <br /> Print Name Adam Piestrzenlewicz Date 315120 <br /> DEPARTMENT USE ONLY / ' R <br /> Application Accepted By: Date Issued: CX/ <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: ~� <br /> Facilt /Site Information —ryr <br /> FA Namet'V FA Address 30�� (t`fDl/ FA# D Z,7 8 J PR# D5tf5,55 2 <br /> FA PE 17Q 5-0WP Reviewed By � Work Plan Date <br /> ❑C57 KT Authonzaton tar Oher lo Sign Pend ❑Workers Comp ❑work es comp Waiver ❑Encroaftenl Permit ❑Access Agreement ❑Lead Agency Approval ❑nMFR- <br /> COMMENTS/CONDITIONS: P�� C 1 LF.I D I.L.rt bV +0 i A-sPei�, b verl C <br /> rd Pjno 2 'dam C,0rY?5 G,P— d du2-to s J c <br /> IWPTYPEI PE 9C FEE INFO JANIT REMITTED CHECK#I RECIIPAD2�YL DATE WELL PERMIT# INVOICE# <br /> Permit Z 1, 1;752X Q C.C. R Z0 \11 o <br /> 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> END 21101ee-01-17 q,/c� IgL' LI.l Pannil Application <br />