COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

��...o SAN JOAQUIN COUNTY 10 ENVIRONMENTAL HEALTH DEPARTMENTLOP SITE MITIGATION HH 600 East Main Street, Stockton, CA 95202-3029 UNIT IV E�• e-/ephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siqov.org/ehd 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 31244 South Highway 33 Cross Street Durham Ferry Road City Tracy zip 95304 APN 255-310-20 Property Owner John Trinkle Address 24551 Kasson Road City Tracy zip 95304 Phone (209)610-2449 C-57 Contractor All Well Abandonment Address 6626 Merchandise Way City Diamond SDringst-ic 84b�6'1 Phone (530)644-1439 Acivancea ConsultantlSub Cntr GeoEnvironmental Inc. Address 837 Shaw Road City Stockton Lic 680227 Phone (209)467-1008 Billable Party Advanced GeoEnvironmental Inc.Address 837 Shaw Road City Stockton zip 95215 Phone (209)467-1008 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(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 ❑HAMMER/DRIVEN 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(i a.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$ BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DE TO 13E PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-4. MW-5 and MW-6 ®PRESSURE GROUT To DEPTH OF 25 FT BELOW SURFACE GROUT SPECIFICATIONS Type 1/11 neat cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ®HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Reference Well Destruction Work Plan.dated 01 October 2010 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify I h r this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, cable C ornla Signed Title/Company Vice President/Advanced GeoEnvironmental, Inc. Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3�L4H �' �,/ 3 7 WORK PLAN DATED 101"l' APPLICATION ACCEPTED BY DATE ISSUED 16 ID AREA U_ 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 q REQUEST PR# g9.0 2- $122x vyz- lob b SR# 612q7 02.903 (' 7 9 r, RO# 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP