FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

"6��t,1f 111;r.v '4� `r S A N J 0 A Q U I N Environmental Health Department COU NTY-- - Greatness rgr•ows here, SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS 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 3081 N Tracy Blvd. City/State/Zip Tracy, CA 95376 Phone (415) 617-5791 Cross Street W Clover Rd. APN 21418041 Property Owner* Stuart Limited Partnership Phone Address P.O. 370298 City/State/Zip Las Vegas, NV 89137 C-57Contractor PeneCore Drilling License# Phone (530) 661-3600 Address 220 N East St. City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor ROUX Associates, Inc. License# Phone (415) 967-6000 Address 555 12th St. Ste. 250 City/State/Zip Oakland, CA 94607 CONSTRUCTION WORK 10 BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) IN HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA K. ® SOIL VAPOR PROBE 1 ElMUD ROTARY CASING THICKNESS TYPE OF CASING: ElSTEEL El PVC ElOTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 IDsp See site plan in work plan GROUT SPECIFICATIONS V DESTRUCTION WORK TO BE PERFORMED: S w l S 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 ❑ PIPE ❑ 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 S n lq/Uin County Ordinance Codes and Standards, and all other applicable California laws. Signed % � Title/Company Principal Geologist / Roux Associates Inc. Riec'�hGa d Maxwell Date December 6, 2022 Print Name ; r =-DEPARTMENT USE ONLY Application Accepted By: , Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: ��II,,,, Facilit /Site Information r f�l S �c— �� `U ale yr l�C �l �Yt U� �'' Ly '� S FA Name V 6t L FA Address �F} 1 ��Z FA# i` '� C' PR# FA PE !� WP Reviewed By Work Plan Date l v 1,6 l ❑C-57 C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement %.gad Agency Approval MFR COMMENTS/CONDITIONS: so : ( q V V'j t h-c—-_� f—r?Y-16'k� u� a, �TT v�J" no rup S-QW WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PER,MIIT# r- INVOICE# Permit y O 4 $,52 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application