Laserfiche WebLink
0 0 <br /> SAN JOAQUIN Environmental Health Department <br /> COUNTY" <br /> ss iron. <br /> SITE MITIGATION 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 /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance With San Joaquin County Development Title.Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 500 East Louise Avenue City/State/Zip Lathrop,CA,95330 Phone 925.674-8400 <br /> Cross Street Harlan Road APN 198-120-08 <br /> Property Owner' RB Louise LLC,Et AL Phone 925-6744WOO <br /> Address 1200 Concord Avenue,Suite 200 City/State/Zip Concord,CA,94520 <br /> C-57 Contractor Advanced GeoEnvinonmental,Inc. License# 680227(C57) Phone 209467-1006 <br /> Address 837 Shaw Road City/StatelZip Stockton,CA,95215 <br /> ConsultanUSubContr ictor NIA License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 12 feet ❑BOLTED TRAFFIC BOX STOVE PIPE <br /> ❑ EXTRACTION(VapmhYaer) ❑ HAMMERIDRNEN OIA.OFBOREHOLE 1.25 inches ❑MULTIPLE CASINGS MULTWEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THMKNESS TYPE OF CASING: ❑STEEL [I PVC ❑OTHER <br /> ® SOIL DORING TWO(2) Ig PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes []No Bo,"Dia: CmiiiDia Casing Depth: <br /> ❑ INJECTION(Al swan.Oraiet ❑ HAND AUGER GROUT SEAL DEPTH 12 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maumum Freefal Depth is 30 Ft) <br /> WEWSOIL BORING IDs GROUT SPECIFICATIONS Portend cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES Fiom_to feet below surface <br /> TREMIE TYPE TO BE USED E]AUGERS [I HOSE El PIPE ❑MUSHROOM CAP ❑3 feet below surface a feet below Surface d>3 heat <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> `�`• ,''I San oaA�r�County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company GeologisVAGE <br /> Print Name W illiam Little Date OW0112017 <br /> DEPARTMENT USE ONLY p " <br /> Application Accepted By: Date Issued: p I -W I i�7 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FAAddressLo-"V- &,lr/ FA# oo .l I-10 PR# <br /> FA PE rGm t+ ; 9 WP Reviewed By vWo Irk Plan Date 0 <br /> 57 ❑C57 Aulhortratbn for Other b Sign Permit one's Comp ❑Woders Comp Waiver ❑Enuo Pemd ❑Acce55Agreemenl atl Agerxy AMroval ®AIIFR <br /> COMMENTSICOND17IONS: <br /> WP TYPE PE I SC I FEE INFO JAMTREMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 3u1d5313 $152 X "5 OLATa4'1 L-X t <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 46 -0 A . jcehd.com <br /> EHD29-01 OMl-17 p Site Miligahon Well Permit Appicabon <br />