FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

d � o�"`tt" •s SAN JOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT OCT 19 2015 < •` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL eq .i..... Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.smcehd.com PF HEALTH 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 Sar)Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. JobAddress +030 S. C.E . D I y 0 N S T R E E r City/State/Zip S To C K TO N r CA Phone (2 o 9) 9 8 3- O 1 2 8 Cross Street LOCK14EED COVRT APN 1-1'1-260-34 95206 Property Owner* STocKroN METROPOLITAN AIM POF%T Phone (-X09) Li68- IOC) Address 5 0 0 0 S. A l K FO P T WAY City/State/Zip S T o C k T o M r C A 9 5 2 0 6 C-57 Contractor V4W 0RILLlNCr1 Itic. License# C-514120904 Phone (209) x}69--}'}o0 Address 3 B 0 6 Dy c k CRE 6 k D R t V r City/State/Zip S T O G h T.0 N 1 C A 9 S 2 l 5 Consultant/Sub-Contractor t;AMAfrE ENV IR0NMENTAL, INCLicense# P-G. # S$56 Phone (-+-+S) 851-T239 Ad d ress F-0, B O X 1,8353 City/State/Zip R rE NO 1 N V $ 9 5 I l CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NA ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL 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 Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaree.Ozwe) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERF ED;.--'� DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 6 !' I✓DOVER-BORE DIAMETER of?inches to depth of 6 0-6S feet(ToTA L D E P T H S) WELL IDs MW-I 1 M W-1. M W r3',)M w,=4)r M W-5 � 114W-It)' ElPRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS NEAT "RTL"D C E M E NT [1 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED GAUGERS E]HOSE []PIPE [)MUSHROOM CAP [J3 feet below surface or feet below surface if>3 feet COMMENTS: RAMACr1= r-- NvIRONMENTAL WOFtk PLAN, DATED TVNE 1912015 (ATTOtChED) END WORK PLAN AF p ROVAL L.I=TTER r DATED TUNE 30, 2015 ( ATTACHED) hereby certify that I am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed ..�,(r - Title/Company C 0 It P. P M E S. 9 A M A Cr C F- N V,1 (N C. Print Name TO S E P 1A R A M A Cr E Date to (t 6 (is DEPARTMENT USE ONLY Application Accepted By: ✓�`� G' /t��0.', Date Issued: zy Grout Inspection By/Dates: Destruction Inspection By/Dates:��j-r- y,.✓vyy u,,,,,�/r �,� pr� , ylir ,S;Sy�,, �5ci�f��f�rnJ Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By I Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver []Encroachment 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 290 j 523 390 ,,r y'�j 5 327 �i�� 1D /y/j 5Ko��352 3 Permit 296 2 3 t 7j $130 X 5 656 5J141 GUTi� 51eao7j52�L EHD 29-01 6-23-2015 Site Mitigation Well Permit Application