Laserfiche WebLink
I " ` SAN JOAQUIN p <br /> Environmental Health Department <br /> —COUNTY <br /> ern " Greatness grows here. <br /> SITE MITIGATION WELL & SORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 963-7697 For 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 2478 North Wilcox Road City/Stale/Zip Stockton, CA 95215 Phone <br /> Cross Street Waterloo Road APN 101-021-74 <br /> Property Owner- Wiley and Shawn Chandler Phone q <br /> Address PO Box 507 City/State/Zip Stockton, CA 95207 _ aS-LZ- 4za- - 6 `j <br /> C-57 Contractor -Peneearo-®nttBTg-' •' 1 N 4L License# 9 10�Y.�-�{',j Phone <br /> Address -22844M1h£7r5T3trnrM 6 5 MAa . Ce1 Clly/StatelZip Woodland, CA95776 `fur-3! 3 tT90 <br /> Consultant/Sub-Contractor ritA '� License# Phone <br /> Address Gy"i; V,41;r„ LAIR ity/State/Zip q <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BonngsWto <br /> L s Require A ss Agreements or ncroachmenl Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LJ MONITORING ❑ HOLLOW STEM BONING DEPTH 8 to 55 fl,1 to 65 R ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 10 SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes [I No Boring Dia: Casing Dia: Gazing Depth: <br /> ❑ INJECTION(Mires e.Ozo,ro1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS QIOSE aIPE <br /> ❑ OTHER ❑ OTH GROUT SEAL PUMPED? M Yes❑ No (Note:Madmilip Reerall Depth is 30 FQ p <br /> WEWS LBORJNGIDS SB-Ith h - GROyr SPECIFICATIONS r .t5 f° <br /> Ky 'sC6y- PeY r eK <br /> DESTRUCTION WORK TO BE PERFORMED: p' d J'4-1ESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE El MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joe uin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Tithe/Company Staff Geologist, Stratus Environmental Inc. <br /> Print Name Steven Mok Date 01/12/23 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: , Date Issued: o�t-'� 7y/5�23 <br /> Grout Inspection By/Dates: (/ I/ V <br /> Destruction Inspection By/Dates <br /> Facilit /Site Information _ <br /> FA Name t-0 2 'Q. FA Address 2 FA# I DO 06 1 PR# 0GItg'ZQ r <br /> FA PE i1 WP Reviewed By Work Plan Date 'Z zQr? <br /> ❑G57 G57AuihorsolbonarptoSill Permit ❑Workers Comp ❑Workers CompWalver ❑Encroachment Permit ❑AccessAgreemn LeadAgenryApproval MFR NES <br /> COMMENTS/ ONDITIONS: - O- -2022 t'y <br /> I� NotPJ'' t'taabf refer 1° P 6Z �" � e� Wo�r I�au 12JcarA rl� abr-0iq'. t P +'Ss"wv,lia <br /> ero 4y 0i,VVjLr °t nCor^re' a�i�t bor> ProPoSnQ �J ,1 . <br /> _ /� Dr m r or-l- l <br /> VIP TYPE PE SC FEE INFO AMT REmmr 13 CHEC # I RECV�'D�B)Y DATE ELL PE'RfMIT# INVOICE# yj <br /> /' <br /> Permit 29n ffi�52k y -It V� I o WLK2 b 'V�a <br /> Cc 15 5 '2 5J 4 $4 s�Dogb3o t <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.st ,e d.com <br /> EHD 29-0104-04-07 Site Mitigation Well Pent Application <br />