|
c•4+'l�'•.� SAN JOAQUIN COUNTY ORIGINAL
<br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP
<br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232SITE MITIGATION
<br /> •. �,*. Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.stdov.org/etW' UNIT IV a;
<br /> �thil
<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 0,1H
<br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made?n compliance witb'San
<br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department.
<br /> Site Location 2908 W. Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN 097-630-32
<br /> Property Buena Park,
<br /> Owner BP West Coast Products Llc. Address P.O. Box 5015 City/State CA •` Zip 904622 Phone e
<br /> C-57 Contractor �rlehR Dri lh N Address qyD j►#a 44 City/StatehneZ _ic 051 L� Phone$tf)313'9840
<br /> Consultant/Sub Gntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400
<br /> Billable Party(consuitantSefViCes, Inc. Address City/State Cordova,CA Zip Phone
<br /> GIS Coordinates:X Y
<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 ❑PIPE
<br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT)
<br /> _❑INJECTION(i.e.Air Soarae,Ozone)❑HAND AUGER GROUT SPECIFICATIONS
<br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑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:
<br /> -Z,R- ESTRCTION METHOD: C_HECKALL THAT APPLY)
<br /> OVER
<br /> #OFWELL(S)TOBE DESTROYEDE-2,E-3,E-4,E-5,E-6,E-9,E-10,E-11,E-12,MW-1,MWyUORE
<br /> DIAMETER(see Well Destruction Details Table)
<br /> WELL IDS:V-1,V-2,V-3,V-4,V-5,V-6,V-7,V-8,V-91S-7,V10/S-8,V-11,V-12,S-1,S-2,S-3,S-4,S-5,S-6,S-4,W PRESSURE GROUT TO DEPTH OF sr '� 'r FT BELOW SURFACE
<br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE
<br /> TREMIE TYPE TO BE USED: AUGERS ❑ HOEF PIPE MUSHRQOM CAP AT(>3 FT) 3 FT BELOVy SURFACE
<br /> COMMENTS {l'(o V-5 4�ZS-Y �Z+f'' 1 •S,E•,I,E'll�E-I�rNW-t,hlW-2� A.r1P /5•! /flayb4 prroj3m,10-pilyk
<br /> 5
<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 laws.
<br /> Signed ����' Title/Company Senior Geologist Stantec
<br /> Print Name Shane Olton Date 7,/. ,? s
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS
<br /> WORK PLAN DATED s
<br /> APPLICATION ACCEPTED Y AT 4A
<br /> GROUT INSPECTION BY' �� FINAL INSPECTION BY DATE
<br /> DESTRUCTION INSPECTION B 4 • 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 /> REQUEST PR#
<br /> so $125.3V 3936 7/ / sR
<br /> 5 0_5s oo O7n
<br /> PR#
<br /> y Z�� 2900
<br /> C-57 WC WAIVE C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC
<br /> EHD 29-01 5/09/12 WELL PERMIT APP
<br />
|