Laserfiche WebLink
o�5f'� • � �� <br /> � [T <br /> 'till, SAN"•• � SAN .IOAQUIN COUNTY L� <br /> "E�.coc <br /> 1Y.- HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> \� ` PJ Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.oro/eh UNIT IV <br /> \C%PORN\ <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 CountyDerelopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> tl G:wltto✓SF-. 95u& <br /> Site Location mer r \Gross Street N Center Street City/State Stockton Zip 4RN APN 139-020-03 <br /> Property lk,.tv Nwroa,CMCn{ `, 5( sf,r (yyr �— <br /> Owner ARtG& Address P.O.Box+R&f City/State fralrRemon Zip "988' Phone 925-275-3807 <br /> C-57 Contractor Cascade Drilling Address 3000 Duluth St. City/State West Sacramento Lic 938110 Phone 916-638-1169 <br /> Consultant/Sub CnfrrA&AD&IUT-+ SSR7Address 8;s QoT77aKAAAXSkrlit, (t. City/State UpYtgLic Phone 9LS.zh"_3a0) <br /> Billable Party AT<NNT'IC R<Wr 4Ecp CbAddress PO a 1257 City/State .S9 Katjwip 9'/S83 Phone9'ZS- .2>5• 3,807 <br /> GIS Coordinates:X 37.9467H Y –/xh1f4Y8 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) - <br /> _Lj INJECTION(Le ar Seams.Omne)❑HAND AUGER GROUT SPECIFICATIONS <br /> _Q OTHER: 0 OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING❑No❑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 /> 1 #OF W ELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: MW-B E PRESSURE GROUT TO DEPTH OF 40.5 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 6GALOFWATER:ONE94 LB SACKOF PORTLAND CEMENT ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE S PIPE ■ MUSHROOM CAP AT(>3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California <br /> Signed Title/Company PROJECT MANAGER/BROADBIENT&ASSOCIATES <br /> Print Name JASON DUDA Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /G E• /o4eb lwe- GU/q-� S7LLCx�tJ <br /> WORK PLAN DATED M 0966 IO I R-Ofy <br /> APPLICATION ACCEPTED BY J•`��IB.CK vrt_ DATE ISSUED /2-Z--11 l AREA /(977 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REOUEST PR <br /> # <br /> 35()2 $ 130x l o sg228 Opl, /1-7-tl SR# x/083 <br /> 35 3 390 s 00 <br /> PR# <br /> (2900) <br /> C-57 V WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT l/ ENCROACHMENT DOC.." <br /> EHD 2M1 7/24/14 WELL PERMIT APP <br />