FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

am3 SAN�IOAQ EnvironmAN Hr-snlrh 4 1 —COUNTY-- RECEIVED oy Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATORI0 7 2017 For Wells and Borings Used for Contaminant Investigations and Re"AVWNTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 48 Hours Advance Notice Required For All Inspections 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 500 East Louise Avenue City/State/Zip Lathrop,CA,95330 Phone 925-674.8400 Cross Street Harlan Road APN 198-120-08 PropertyOwner` RS Louise LLC,Et Al. Phone 925-674-8400 Address 1200 Concord Avenue,Suite 200 City/State/Zip Concord,CA,94520 C-57 Contractor Advanced GeoEnvironmental,Inc. Licens 80227(C57) Phone 209-467-1006 Address 837 Shaw Road State/Zip Stockton,CA,95215 Consultant/SubContractor NIA Li se# Phone Address ItyIState CONSTRUCTION WORK TO BE PERFORMED:" e: Offsite Borings Wells ire Acoes reements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLAT TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW EM BORING DEPTH 12 feel ❑BOL TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ H ER/DRIVEN DIA.OF BOREHOLE 1.25 inches ❑MULTIPLE SINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE UD ROTARY CASING THICKNESS TYPE OF CASING: STEEL ❑PVC ❑ OTHER ® SOILBORING 3 PUSHPOINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soxa Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 12 fast TREMIE TYPE TO BE USED: AUGERS [I HOSE IJ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 3 t WEW SOIL BORING as �� GROUT SPECIFICATIONS Portland cement NN DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL We ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surfac f>3 feel COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with SaA Joaquin Cao my Codes and Standards,and all other applicable California laws. Signed , / ) ( �jCs{GfQ e Title/Company GeologisUAGE Print NameWllliam Little Date 0810112017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Wakens Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit $152 x 1868 E Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 I www.sjcehd com EHD 2401 0841-17 Site Mitigation Well Permit Application