FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

t �o•,Ag�.�o SAN JOAQUIN COUNTY FIL ' COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP N �� '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITEMITIGATION • ;.,. P Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd U t. WELL & BORING PERMIT APPLICATION IVPP FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JA/V 2 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �V 2014 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in cps li ec.Wtth C n Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 712 South Sacramento Street Cross Street West Spruce Street City Lodi zip 95240 APN 045-32 lG' LTJ� Property Owner PG&E Address 3401 Crow Canyon Road City San Ramon Zip 94583 Phone 925-383-9517 )O=Contractor PIVOX Address 7595 Irvine Center Drive,Suite 152 City Irvine Lic Phone 949-727-1400 Consultari Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine Lic 885321 Phone 949-297-4444 Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine zip 92618 Phone 949-297-4444 GIS Coordinates:X 3191, 17-Stc Y c ty - $.?Z4 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION Q.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 14 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDS:OBS-1 through OBS-S,SVE-1,SG-2,SG-7 through SG-g.SG-12 through SG-14 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS All soil vapor wells will be removed during remedial excavation,and the areas backfilled with Gean Boll or slurry. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,ySd all ap lic ble-eattfornla Laws. Signed Title/Company r/LG7 ✓ /Terra Pacific Group Print Name Rick McCartney Dateezz/9 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 71 Z S, 59�R 4rnFN� SIT, ( WORK PLAN DATED Q ro&—.R— Z v ?2- APPLICATION ACCEPTED BY j_ DYE Kk'1 DAT REA GROUT INSPECTION BY FINAL INSPECTION BY I�{� DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE Rio# INVOICE Q © REQUEST PR# Z 1O 5 $125 xy O 1 U l �D(AWT-4 SR# 9 RO# 3500 PR# 2900 C-57 (,,- WC WAIVER YLIW C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHMENT DOC