FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ORIGINAL a K ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton , CA 95205-6232 SITE MITIGATION -:� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sinov.ora/eh WMza • rF' R D WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION FEB 0 5 2015 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIIIoNMLNTEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made inl `�IR�Igr9nfrt', Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. City of S ocktion Right-of-Way North of Intersection Site Location of North Laurel s and eat CRV99street Lrel s and & City/States Zip APN N/A ICP yftwvpvr Property city o£ Stooktoa a North sl Dorados . Stockton - -aca4 Owner Address ' City/State s Zip ' Phone C-57 Contractor All Well Abandonment Address 33 69 Fitzgerald Road suite a City/State Rancho cordovaLics' Phone - ConsultanUSub CMr Advanced Deoeam,reame Inc .)dr837 Shaw Road City/State Stockton Lic s a 2' Phone aoe-ae7-loos. Billable Party ME Address 837 Shaw Road City/State $CO"4iOe Zip 95215Phone 209 - -1006 GIS Coordinates: X 37. 95213v - 121 . 7.G 507 CONSTRUCTION WORK TO BE PERFORMED: El NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs EIWELL IDs and Nw-22 , IW-4 and IW-5 ❑ OTHER IDS TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2 0 MONITORING O HOLLOW STEM DIA. OF BOREHOLE am ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _O EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS ° ' 215 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER _O SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 35 a 95 TREMIE TYPE TO BE USED: I9 AUGERS El HOSE OE PIPE _0 SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: El Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) =E] INJECTION ( e Air SDame Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS F gallons water per as Its hag _O OTHER: ❑ OTHER: APPROX. BORING DEPTH 551 and 120t 17 BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING IS No ❑ Yes: Casing Dia: Casing Depth: Boring Dia:_ COMMENTS: see attached work plan, work plan approval letter and site plan. W-2 0.tUs� thy. WQLL- $ NOTE : OFFSITE WELLS & BORINGS REQUIRE ACCESS AGI�96 ENT SOR ENCROACH ER ITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED E] OVER-BOREDIAMETER OF INCHES TO DEPTH OF FT VVELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO Fr BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatiall applica a California laws. ons Signed Title/Company Project Geologist/ ADE Print Name Daniel S. villanue'ra Date 02/03/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE DDRESS c. e4 .yalu7— 5 f ri '1b� K7 WORK PLAN DATED APPLICATION ACCEPTED BY AV o DATE I 46=2WMA � GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE � ) REQUES PR # 3So I $ 130x 7 9 /O / 1V2Z 00umv A ' S` f5 SR# 714170 3S°3 390 RO # 3500 PR # 11 2900) C-57�� WC WAIVER � C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCy EHD 29-01 7/24/14 WELL PERMIT APP