Laserfiche WebLink
z.%pd}UIN Z,•, � �'Ii <br /> SA N J O A Q U I N Environmental Health, 0�4 en°t <br /> MF �I <br /> COUNTY 0 3 8 <br /> GrQaLness grows here. Fp'gRhr'�Iyr_ <br /> .— ail <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 8606 Thornton Road City/State/zip Stockton, CA 95209 Phone <br /> Cross Street Davis Road APN 072-420-19 <br /> Property Owner* Gian Singh Phone <br /> Address 1557 Lincoln Rd. city/State/zip Yuba City, CA 95993 <br /> C-57 contractor Cascade Drilling License# 938110 Phone (510) 578-0858 <br /> Address 120 S. 23rd St. City/State/zip Richmond, CA 94804 <br /> Consultant/Sub-contractor ATC Group Services LLC License# Phone (209) 579-2221 <br /> Address 1117 Lone Palm Ave., Suite 201 B City/State/zip Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft. ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 3 I rl- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 4 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air soarge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 10 ft. 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 SS1-SS4 GROUT SPECIFICATIONS neat cement <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 /> ��//// San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed «!`&O� _ Title/Company V.P.Operations/Cascade Drilling, L.P. <br /> Print Name Ralph McGahey Date 12/13/2018 <br /> DEP R ENT USE ONLY <br /> Application Accepted By: Date Issued: T&_ j /tc� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name ��N. - .o <br /> �Gyb1 FA Address �&('Olr' j 1n o r,Ay�•� e-� FA# �V23'Z I PR# <br /> FA PE ,0 WP Reviewed By Work Plan Date <br /> ❑C-57 [9'65-7 Authorization for Other to Sign Permit C -f6rker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement eLead Agency Approval G216FR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit s>S 3 13 $152 X 3 y �� i z;?rr �iC lz o r UJ COO 3 0`1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 l F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br /> ,.� P 3 5V3 �GsZx3 113') 7 <br />