COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

FILE COPY aP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP s 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV 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 Health Department. Site Location 248 Industrial Cross Street McKenna Cit, Stockton Zip 95206 APN 177-280-20 Property Owner Steve Donell, Receiver Address 12121 Wilshire, #1120 City Los Angeles Zip 90025 Phone 310-207-8481 C-57Contractor EnProb Address P.O. Box 8093 City Oroville Lic 777007 Phone 530-589-2019 Consultant/Sub Cntr Pinnacle Env. Address P.O. Box 904 City Clayton Lic Phone 925-673-5500 Billable Party Steve Donell Address 12121 Wilshire, #1120 City Los Angeles Zip 95206 Phone 310-207-8481 GIS Coordinates:X 37.90614 Y 121.26967 CONSTRUCTION WORK TO BE PERFORMED: Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER) ❑SOIL BORING IDs 8 direct oush soil borings up to 10 feet to oroundw-ter with soil and groundwa-er sampling ❑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 ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: C3AUGERS ❑HOSE C1PIPE 8 [1SOIL BORING [3PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.Ozone l❑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: All borings to be abandoned same day as completion. No open boreholes left overnight. NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Q HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS The 8 temporary monitoring wells are for grab groundwater samples to-be ciosed same day. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby I that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Reg ions,a d all app"ca I a'ornia Laws. Sig4d Title/Company Principal/Pinnacle Environmental Inc.cl Print Name Pete Cl'oven Date Ca L �1 Q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 2-qIB lk)J)USTetd} D21(JE WORK PLAN DATED dU64S-r //P ZO/2 APPLICATION ACCEPTED BY J. lOf3Krin'l DATE ISSUED 8-17-12- AREA16?? 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 REQUEST PR# �qa 5 $125 X i SR# G SSZ`I RO# 3500 PR# (2900) C-57 [_ WC !/ WAIVER 7= I i7 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC ![}