FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, GA 95202-3029 UNIT IV . c� . .� --,a;P• Telephone: (209) 488-3454 Fax: (209) 468-3433 Web:www.s' o�.or �e EVED treau WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIW.R 2 O 2011 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 hff4hvpflEjoL Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmeFERMIT/SEWCES Site Location 4100 East Fremont Street Gross Street Oro Avenue City Stockton Zip 95215 APN 143-336-46 Property Owner Rick Grewal Address 4166 East Fremont Street City Stockton Zip 95215 Phone (209)463-5294 0 �4�nriy�l-rl C-57 Contractor RS1 DrillingAddress 226 North East Street City Woollard Lic 9 s Phone :530)668-2424 Consultant/Sub Cntr Advanced GeoEnvironmeniai Inc.Address 637 Shaw Road City Stockton LIC 686227 Phone 269 467-1666 Billable Party Advanced GeoEnvironmental,Inc. ,Address 837 Shaw Road City Stockton Zip 95215 Phone (209)467-1606 i GIS Coordinates:X Ypop CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs . .. I TYPE&#OF WELUBORiNG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS. _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water []HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 7REM1E TYPE TO SE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION ti.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS i ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 0 No❑Yes:Casing Dia: Casing Depth: Boring Dia_ COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED- DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 4 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 2 INCHES TO DEPTH OF 71 FT WELL IDs: MW-1,MW-2,MW-3,MW-4 ®PRESSURE GROUT TO DEPTH OF max 70 FT BELOW SURFACE GROUT SPECIFICATIONS Type 1111 Neat Gement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ®HOSE ® PIPE ®MUSHROOM CAP AT(?3 FT) min 3 FT BELOW SURFACE COMMENTS As described in the AGE-prepared Well Destruction Work Plan dated 19 April 2011. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatio d all applic orni aws. Slgned Title/Company Staff Scientist/Advanced GeoEnviron ntal Inc. Print Name Rebecca E.Natal z Bate y oma DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_ -4100 E. Fr e m o>'t+ S+Yee-- WORK PLAN DATED D I APPLICATION ACCEPTED BY Y DATE ISSUED 2-2 I AREA.1 4:5 q GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ve if L) n! ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# i 35b2 $122X �48 .-32689 `6cwC 4 1 12?-0 1 it SR# DD 6,2380 01 RO# 3s03 3116,60 3616.00 35oD 2,4,-0 17 S s 4, 0[� 290 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP