Laserfiche WebLink
$AN ,JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> G< < :�t,l >ss prows her, <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> j 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 fora permit to Construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address 720 W. Weber Avenue City/State¢Ip Stockton/CA/95203 Phone N/A <br /> Cross Street N. Lincoln Street APN 13737001 <br /> Property owner• E.J. WIIiams Properly Management Phone 209-473-4022 <br /> Address P.O. Box 718.5 City/Stateop Stockton/CA/95267 <br /> C57 Contractor Cascade Drilling License# 1058336 all 3/30/f-1 Phone 916-638-1169 <br /> Address 3000 Duluth Street City/state/Lp West Sacral onto/CA/95691 <br /> Consultant/Sub-Contractor Tdhvdro, Coro. License# .LNA Phone 520-730-1442 <br /> Address 2520 Stanwell Drive, #105 City/StateOP_Concord I CA/94520 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreementsor Encroachment Peraft <br /> TYPE OF WELLIBORINO NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 9.2 N has W BOLTED TRAFFB BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vaponwamq ❑ RAMMERARIVEN UW.OF BOREHOLE 4inches ®MULTIPLE CASINGS MULTHEVEL WELL CASING DMA <br /> W SOILVAPORPROBE X, MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC M OTHER Te6nn Tubing <br /> ❑ SOIL BORING PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes IR No Boag Bla 4 inches Cadng Dia:1/4 inch Casing Depm:5 N hog_ 9R logs <br /> ❑ INJECTION fAMaroe.omreT ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETOBE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ® OTHER:Air Knife GROUT SEAL PUMPED? ❑Yes IC4 NO (Noe:MUIrnum Treated Dept)Is 30 FI) <br /> WEAL BOIL BORING IDs _ _ GROUT SPECIFICATIONS Neal Cement Grout <br /> 110" ls1S"I" SAA£86I <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL 6r APPI YT <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth ol_feet <br /> WELL IDS ❑PRESSUREGROUr To depth of feel below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIETYPE TO BE USED AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface If>3 feet <br /> OMMENTS: <br /> I hereby certify that I am authorized to complete this applicallon and that the work will be done in accordance with <br /> San J utn C n Ordinance Codes and Standards,and all otherapplicable C Ilfornia laws. <br /> Signed��/r- J / TRIelCompany C1BeL T T IHlypprt, <br /> Print Na .7o140 (AfLfLbI,.. Date 9110 rz/� <br /> QEr01IJSE ONLY <br /> Application Accepted By: 1A Date Issued: 2 Q <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facie /She information L7J <br /> FA Name L� b(P"IJ l' FA Address (' VV �el� FA# OZ3S PRO bSTi b76 <br /> FA PE Za O WP Reviewed By Work Plan Date <br /> ❑C57 Z7Aulhorlzationfa0Nerto Sbn Pwmll ❑Workeesomp ❑wohels Camp WalverVV❑EnemachmenlPennit ❑Acwssfpleemant ❑Lead AgawyAppmval ❑NFRR� <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE I Be FEE INFO JAINIT REmirrEol CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 3l $152 x Z L R I(o Zo <br /> 1868 E. Hazelton Avenue I Stockton California 95205IT 2209 468-34201 F 209 464-0138 1 www.sjoehd.com <br /> , <br /> ERD 29"01084H.17 613115387, <br /> Sae Mfigetlon We I Pbml Application <br /> 5p0 g�D­-� <br />