Laserfiche WebLink
SAN JO A QU I N Environmental Health Department <br /> C O U N T Y <br /> SITE MITIGATION 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 /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 17550 Shideler Parkway City/State/Zip Lathrop, CA 95330 Phone NA <br /> Cross Street West Yosemite Avenue APN 198-230-05 <br /> Property Owner" City of Lathrop Phone 209-941-7430 <br /> Address 390 Towne Centre Drive City/State/Zip Lathrop, CA 95330 <br /> C-57 Contractor Gregg Drilling License# C57-1044456 Phone 925-313-5800 <br /> Address 950 Howe Road City/State/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Geosyntec Inc. License# NA Phone 916-637-8048 <br /> Address 3043 Gold Canal Drive, Suite 100 City/State/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑ HOLLOW STEM BORING DEPTH 285 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE r <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 � 5✓ <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS— TYPE OF CASING: EI STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes KI No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Swarm.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IN PIPE <br /> ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? IN Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs Boring:B-12 GROUT SPECIFICATIONS Type II-V <br /> Well:PW-47 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE [:]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: 1 monitoring well will be installed to a maximum depth of 300 ft bgs. See attached table with well specifications. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �` ="' Title/Company Senior Geologist/Geosyntec Consultants, Inc. <br /> Print Name Nicole Gotberg Date April 25,2019 <br /> / ® DEPARTMENT USE ONLY <br /> Application Accepted By: Nuo'ZPµ­ oe Date Issued: �E7ZZ0/9 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name ' FA Address /e, 7-77 � FA# Z y 7 ds( PR# <br /> FA PE 2 WP Reviewed Bys� t2oWork Plan Date <br /> ❑C-57 C-57 Author nation for Other to Sign Permit Worker's Comp []Worker's Comp Waiver TEncroachmentPermit ❑Access Agreement Lead Agency Approval VfMFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit zgOl 313 $152x if 6-2 Va 1170 ovA S/7//9 r✓jti�3 8� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br /> EHD 29-0108-01-17 Site Mitigation Well Permit Application <br /> Wp zl,3 5-Z-315",3 It L10-co //70 'OV4 Y/�(o/9 S/Zvo o-OS52 <br />