FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

o�a`'r•R SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 �;•.-:. ,::.�;:P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com /FOR/ SITE MITIGATION 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 San Joaquin County Well Standards. Job Address 701 East Charter Way City/State/Zip Stockton, CA, 95206 Phone 209-467-0305 Cross Street Stanislaus Street APN 147-343-11 Property Owner" Swaran Chouhan Phone 209-467-0305 Address 1632 Paola Place City/State/Zip Manteca, CA, 95337 C-57Contractor BC2 Environmental License# 969758 Phone 714-412-2990 Address 1150 W. Trenton Avenue City/State/Zip Orange, CA, 92867 Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORNG DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DLA OF BOREHOLE ❑MULTIPLE CASINGS❑MULT11EVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boong Dia: Casing Dia: Casing Depth: ❑ INJECTION iPirSoaae.ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefal Depth is 30 FI) WEW SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL Tt-IATAPPLY) #WELLS TO BE DESTROYED 2 ®OVER-BORE DIAMETER of 8 inches to depth of 151 feet WELL IDs MW-8 and MW-9 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: See work plan for additional details; CMT wells to be overdrilled using sonic drilling techniques. ljlereby certify that I am authorized to complete this application and that the work will be done in accordance with San J in County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Geologist/AGE Print Name Daniel Villanueva Date 10/27/2015 DEPARTMENT USE ONLY Application Accepted By: //�/f'� 7�/�%��G � Date Issued: Grout Inspection By/Dates: tZA^rA e- Zo 1 �, *1 IA) —ci 1 I2Z Ib 1M IAJ—se Destruction Inspection By/Dates: Facili /Site Information FA Name I ssFA# PR# FA PE WP Reviewed By Work Plan Date ❑G57 ❑G57 Authorization for Other to Sign Pem it ❑Workers Camp ❑Workers Comp Waiver ❑Enaoachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit $130 x C' 12 3tt =�17 /� S'�t QG'Jj S EHD 29-016-23-2015 Site Mitigation Well Permit Application