Laserfiche WebLink
OP,pVI/y..0 <br /> °1 SANsa10AQUIN Environmental Health Department <br /> COUNTY <br /> c�<I�oP'� Greatness grows here. <br /> Cz <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION m� <br /> For Wells and Borings Used for Contaminant Investigations and Remediation Z <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rn-+ IV <br /> 48 Hours Advance Notice Required For All Inspect' ns, " CE9 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or insta e w described. 11 Fin <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and t Joaquin County Well StaT�idards. <br /> Job Address 2700 W. Washington Street City/State/Zip Stockt0 \ Phone <br /> Cross Street Navy Drive APN 145-030-12 <br /> Property Owner* Buckeye Partners LP - Jeff Brudereck Phone (610) 904-4019 <br /> Address Five TEK Park/ 9999 Hamilton Blvd. City/State/zip Breini vill PA 18031 <br /> C-57 Contractor Cascade Drilling License# 93 1jr0/ Phone (530) 662-2829 <br /> Address 2083 E. Main Street City/State/Zip odland CA 95776 <br /> Consultant/Sub-Contractor Stantec Consulting Services License# Phone (916) 472-3915 <br /> Address 3875 Atherton Road City/s e/ ' ocklin CA 95765 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNV a ire Ac ss Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECI C ONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKN S TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTO NG ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER f((OUT SEAL PT TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: ROUTS PU ED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs sP IF ATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 34 ®OVER-BORE DIAMETER of A inches to depth of 3_feet <br /> WELL IDs OS-32 thru OS-57 ®PRESSURE GROUT To depth of 37 feet below surface <br /> GROUT SPECIFICATIONS bleat Cement ❑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 /> COM NTS- <br /> We Ts will be over-bored unless site li ' ations prohibit access with augers. <br /> I hereby certify th I am auth Ized to complete this application and that the work will be done in accordance with <br /> Sa J quip Cou Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed n Title/Company Sr. Project Manager/ Stantec <br /> Print Name Dan Schreiner Date 10/11/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD29-01 08-01-17 Site Mitigation Well Permit Application <br />