Laserfiche WebLink
Copy <br /> ora� '�.�•. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sfgov.oro/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> • Joaquin County Devion Is elopment opment Title,made to San IChapin County ter 9-11 5f3r and h Itto construct Standards of the/or San Jtall the work described.oaquln County Environmental lHealthion Is made Departmentn compliance with San <br /> Site Location 3138 E.Main St .Cross Street S.Golden Gate AvgItylStateStocktozip 95205 APN 157-104-03 <br /> Prope 'Y <br /> #170-7T7— <br /> Ow rAuntbrook Holdings A 0,,2351 Sunset Blvd City/state Ip 95766 Phone916-40 -4499 <br /> n 1 Ass 11 Twin Palms Dr /sl a�Ic 695970 Phone831-662-8178 <br /> C-57 Contractor, Address C <br /> RDM gg❑❑VV1ronme—n_r_ ; . oc 1zrr;�A . PG 7124 * 916-415-1134 <br /> It t75ub Cntr Address Brookshire Drc 'oc1CY1`T�-011 UCPG�a� nvlro�cAddrass 6280 Brookshire DrCity/State zip 95677 Phone916-415-1134 <br /> Billable Party <br /> G**GMric�iae errington <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT PR0BE.HYOROPUNCH.HAND-AUGER,OTHER) <br /> IN SOIL BORING IDs RDP1 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLBORING ,`1 <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _EI MONITORING LHOLLOW STEM DIA.OF BOREHOLE2- le:}MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _I]EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5 D TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE tfPIPE <br /> 1 (SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED.Lf Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) SJCEHD specs <br /> _Q INJECTION(a All SPalo ozonsi El HAND AUGER GROUT SPECIFICATIONS Neat cement mixed in accordance w/ <br /> _Q OTHER: ❑OTHER: APPROX.BORING DEPTH 50 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Die: Casing Depth:_ Berne DIB:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL THAT APPLY) <br /> • <br /> III OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: C]PRESSURE GROUT To DEPTH of FT BELOW SURFACE <br /> TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS El EXPLOSIVES FROM <br /> TREMIE TYPE TO BE USED:[IAUGERS ElHOSE C1PIPE LJMUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulation all app(�}le�j611fon' ws. <br /> Signed 66N Title/Company Princ iTJal Geologist/RDM Environmental <br /> Print Name M1C ael . Berrington Date 10-22-13 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS .N ' <br /> WORK PLAN DATED f-t-r`I'� S /3 AREA /G t7rl <br /> APPLICATION ACCEPTED BY J�O&Ku s—I DATE ISSUED /(nom S <br /> FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTSICO N DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# R�E+CV'D BY DATE REQUEST PR# <br /> a�DS 5125x / 12. o(n2y2(. cCCfr / - / SR# 4Ua/Y <br /> RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> G-57 f/ WC ✓WAIVER _ C-57.LETTER OFAUTHOR17ATION TOSIGN.PERMIT_ ENCROACHMENWDO PERM L'P <br /> EHO 29-01 5/09112 <br />