FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

r RE(ycIVEDQ R I G I N A L `'I� SAN JOAQUIN COUNTY JUL 3 0 2014 ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA FWBQtWNTALHEALTHSITE MITIGATION •: <:• :P Telephone:(209)468-3147 Fax:(209)46"433 Web. M6T1%TN( 4Pd UNIT IV �rr;ot2 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 He�Itt�Department. Site Location 7675W.11th Street Cross Street Poplar City/State Tracy,CA Zip9 33 cf APN 250-140-12 Property Yvonne Miller Owner Address P.O.Box 366 City/State Tracey,CA Zip 95378 Phone 209-835-3466 C-57 Contractor Greg Drilling Address 950 Howe Ave. CltylState Martinez,CA Lic 4 5165 Phone Consultant/Sub Cntr Cardno Address 1117 Lone Palm Ave.,Suite 201 B CitylState Modesto,CA Lic 95351 Phone 209.579.2221 Billable Party Cardno for Yvonne Miller Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Zip 95351 Phone 209.579.2221 GIS Coordinates:X 37.740 Y-121.400 'Z7-7'"15 -'P 2/ jQn_/ CONSTRUCTION WORK TO BE PERFORMED: ©NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDS ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING Q HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ,_❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.AirSoarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: Q OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dla: COMMENTS:CPrnPnt Sk'rt snrroLnrIinq well hnx will he reolared NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 14 #OF WELL S)TO BE DEST OYED ❑OVER-BORE DIAMETER OF - INCHES TO DEPTH OF 20-27 FT WELL IDs: MW 1-9. AS-�ITS-2. DP 1-3 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIETYPE TO BE USED:❑AUGERS ❑HOSE D 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 hav prepared this applicat5a and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all ap cable C t'to r a la Signed i! Title/Company Staff/Cardno Print Name Charlie Selkow Date 7^A2IL-t 4 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7G?j, LJ, /[ 'Y 57-t % � WORK PLAN DATED J ll J.N t% 2.014 APPLICATION ACCEPTED BY yOt9.C�fit H't DATE ISSUED AREA /(0 t^1 GROUT INSPECTION BY FINAL INSPECTION BY 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 a /� REQUEST PR* _ 35,02 x 11 2 2 toJ� l �u 7-3c%)-<9 SR# 20 2,P 3so3 39� (3o0 PR# 2900 C-57 d WC WAIVER _ 0-57 LETTER OF AUTHORIZATION TO SIGN PERMIT f/ ENCROACHMENT DOC N EHD 29-01 5/09/12 WELL PERMIT APP