Laserfiche WebLink
ti.,50-1. IN" <br />I hereby certify th I have prep re <br />Regulations, andjI applicabl <br />Signed <br />Print Name James E. Gribi <br />ORIGINAL <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT LOP <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br />Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siqov.onalehd UNIT IV <br />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 />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 <br />Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />3310 & 3330 E. Main St. <br />Site Location Cross Street S. Netherton Ave. City Stockton zip 95205 APN 157-110-01 <br />Property 43385 Business Park Dr. <br />Owner EH National Bank Address Suite 200 City Temecula zip 92590 Phone 951-232-3077 <br />485165 Phone 925-313-5800 <br />Phone 707-748-7743 <br />N 9A4 5 1 0 phone 707-748-7743 <br />C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic <br />Consultant/Sub CntrGribi AssociatesAddreSs 1090 Adams St. City Benicia <br />ij Billable Party Gribi Associates Address 1090 Adams St. City Benicia Zip p <br />GIS Coordinates: X <br />CONSTRUCTION WORK TO BE PERFORMED: CZ] NEW WELLJBORING (CPT, GEOPROBE, HYDROPUNCH HAND-AUGER, OTHER) 123 SOIL BORING IDs B-1, B-2, B-3, & B-4 <br />p WELL IDs 0 OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2 " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />El EXTRACTION: Vapor/ Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />El SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br />4 E9 SOIL BORING I2g PUSH POINT (GP/CPT) GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH 1S30 FT) <br />0 INJECTION (Le .Air Soaroe. Ozone) 0 HAND AUGER GROUT SPECIFICATIONS p6,s4cr coviotiT , ,vo i364,76/V174 <br />ID OTHER: 0 OTHER: APPROX. BORING DEPTH a.)' 0 BOLTED TRAFFIC BOX OR El STOVE PIPE <br />CONDUCTOR CASING El No 0 Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># OF WELL(S) TO BE DESTROYED 0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS 0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: 0 AUGERS D HOSE 1=I PIPE <br /> 0 MUSHROOM CAP AT (3 FT) FT BELOW SURFACE <br />COMMENTS <br />5 WORKING DAYS NO ICE 3 QUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />ation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />S. <br />Title/Company Sr. Geologist/Gribi Associates <br />Date <br />DEPARTMENT DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE SITE ADDRESS -3310 MOWper . siakeir70/0 <br />WORK PLAN DATED (9 -16 - <br />APPLICATION ACCEPTED BY J. Joe /cam DATE I FS WE AREA <br />=-417ATE6?- 21/44„ GROUT INSPECTION BY FINAL INSPECTION BY rip • IP <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # <br />- <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />$ 125 x 1 <br />> 5-6° <br />.5*ce e:7`0 8 4?-17 SR# <br />-90'2) -75-- RO # <br />(3500) <br />PR # <br />(2900) <br />WC t/ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 7 ENCROACHMENT DOC A./.4 <br />DATE <br />C-57