Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 17676 Corral Hollow Road citylstaterzip Tracy/CA/95376 Phone <br /> Cross Street TIM APN 25118003 <br /> Property owner* Connolly Ranch, Inc. Phone (209)835-7913 <br /> Address P.O. BOX 811 city/state/zip Tracy/CA/95378 <br /> C-57 Contractor Gregg Drilling and Testing, Inc. License# C57 485165 Phone (925)313-5800 <br /> Address 950 Howe Road citylstaterzip Martinez/CA/94553 <br /> Consultant/Sub-Contractor License# Phone <br /> Address Clly/StatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: ONsite Borings)Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORINO INUMBE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vap&Malei) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE O MUD ROTARY CASINGTHICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Borrg Dia: Casing Da: Casing Depth: <br /> ❑ INJECTION Wrscum,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note Mwinum I'mefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> It WELLS TO BE DEgTROYEO Dine t9) ®OVER-BORE DIAMETER of 14 inches to depth of 27_97 feel <br /> w•25M•02,W25M-o3:-w=23311v-nsw•2slPze;W25TaTu;W-2acf5, PRESSURE GROUT To de WELL IDs,,,,,•,, ,e ,. R�,, ��, • depth of feet bebwsudace <br /> GROUT SPECIFICATIONS neatcement ❑EXPLOSIVES From_to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE @PIPE MUSHROOM CAP 0 3 feet below surface or feet be'ow surface if>3 feet <br /> COMMENTS: <br /> hereb ceRity a I am authorized to complete this application and that the work will be done in accordance with <br /> San J a in County rdinance Codes and Standards,and all o her applicable C Iifor is laws. <br /> Signed —Title/Company ' hQ v Uk�('i <br /> Print Name Date <br /> DEPART ENT USE ONLY <br /> Application Accepted By: Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dale - "I- I <br /> Facili /Site Information <br /> FAName i ✓,V'rwrt. FAAddress 5"41- L""tA FA# OO2N,*�l 'Z PRiI <br /> FA PE t7 'V1 I <br /> WP Reviewed By L x Wmk Plan Dale <br /> ❑C-51 7Aulhodzal1onfur Olherlo%nPerml ars Carp ❑Workefs OanpWa;w ❑EnmKinnent Permit 011oocMAgmemenl 91II&AgorqApproval RtfR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE` <br /> —d <br /> Permit .�jj02, Sly S152x � �IW WMIX I k NA 11AW PaaUl ti.► <br /> 1868 E Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 0941-17 See MAgawn Well Permit Application <br />