Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> _ _-COUNTY <br /> Greatness tgrows here, <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 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 671 Scarlett Place City/State/Zip Tracy, CA 95376 Phone (650) 222-8403 <br /> Cross Street Gomes Drive APN 21419037 <br /> Property Owner* Rene Ruvalcaba Phone <br /> Address P.O. 370298 City/State/Zip Las Vegas, NV 89137 <br /> C-57Contractor PeneCore Drilling License# Phone (530) 661-3600 <br /> Address 220 N East St. City/State/Zip Woodland, CA 95776 <br /> ConsultantlSub-Contractor Roux Associates, Inc. License# Phone (415) 967-6000 <br /> Address 555 12th St. Ste. 250 City/State/Zip Oakland, CA 94607 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) [3& HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA <br /> ® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs See site plan in work plan GROUT SPECIFICATIONS <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 ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet 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 /> r1 San o q�In County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed '`� �'- Title/Company Principal Geologist/ Roux Associates Inc. <br /> Print Name Richard Maxwell Date December 13, 2022 <br /> ,i (�� DEPARTMENT USE ONLY 2 I Lk /� D <br /> Application Accepted By: �r_ - Date Issued: <br /> Grout Inspection By/Dates: Q1^ G <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address 3 OS i U„ �, FA# 0 0 PR# o <br /> FA PE _ WP Reviewed By Work Plan Date <br /> ❑C-57 PC-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit 0 Access Agre_ement .JLead Agency Approval \ MFR <br /> COMMENTS/ ONDITIONS: be- <br /> 1 <br /> o,r a rr, � � -1-�n ; � s �i� CM- 61r14 <br /> t� twoieG <br /> 1/VP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' BY, DATE WELL PERMIT# INVOICE# <br /> Permit Q) $_152x IV/ too <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com L <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application �/� <br />