FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

COPY o�q�'"' c • SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • •-� �;'p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sogov.org/ehd UNIT IV WELL &BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 515 West Charter Way Cross Street S. Lincoln st City/State Stockton Zip 95206 APN 147-074-08 Property Owner Donald Rogers Address 11900 South Union Road Cit /State Manteca 95336 City/State Zip Phone 209-464-5780 C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City/State Sacramento LIC 848359 Phone 916-363-9355 Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 680227 209-467-1006 Consultant/Sub Cntr Address City/State Lic Phone Billable Party Donald Rogers Address 11900 South Union Road City/State Manteca Zip 95336 Phone 209-467-1006 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs WELL IDS SP-6A and SP-7A ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑x HOLLOW STEM DIA.OF BOREHOLE 8„ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 0.218 TYPE OF CASING: ❑STEEL O PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 371 TREMIE TYPE TO BE USED: EIAUGERS ❑HOSE EIPIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ®INJECTION(i. .Air S ar e.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Type I/II _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 451 ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING®No ElYes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT 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 Regulations,an applicable California laws. Signed ✓V Title/Company Project Geologist Print Name Daniel Villanueva Date 05/13/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED (Z IL 3v 2Ur APPLICATION ACCEPTED BY J J d t�Klt✓i'L DATE IS D 5-1_10--1-7%- —AREA �G GROUT INSPECTION BY FINAL INSPECTION BY 40 P" DATE DESTRUCTION INSPECTION BY DATE .. COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE (� ?? q REQUEST PR# lOI $125x 2 Z^ J(Zvc ( �CtrU�(� J�'/U-(3 SR# p �5 RO# I (3500) PR# (2900) C-57 WC WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC N/9 EHD 29-01 5/09/12 WELL PERMIT APP