Laserfiche WebLink
c. SAN JOAQUIN COUNTY <br />--�� -'off\ <br />r Z` ENVIRONMENTAL HEALTH DEPARTMENT <br />c �I <br />-i 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 />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 8010 AirportWay City/Staterzip Stockton, CA 95206 Phone <br />Cross Street Stimson Street APN <br />Property Owner" California Army National Guard (LTC Belinda May) Phone 916-854-1483 <br />Address 3900 Roseville Road cityfstateizip North Highlands, CA 95660 <br />CS7 Contractor Penecore Drilling License# 906899 exp 11/30/17 Phone 530-661-3600 <br />Address 220 N East Street City/State/Zip Woodland, CA 95776 <br />ConsuhanUSub-Contractor ECM Consultants License# Phone _ <br />Address 3525 Hyland Ave, Suite 200 City/State/Zip Costa Mesa, CA 92626 <br />CONSTRUCTION WORT( TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MO4LTORING ❑ HOLLOW STEM BORING DEPTH 45 S ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />D EXTRACTION (VaporWateo ❑ HAMMERIDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ SOA. BORINGM PUSH POINT )GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No BwN Oa: Casing Dia: Casing Depth: <br />M INJECTION (A. s,, Omer,.) __23__ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE M PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? M Yes ❑ No (Ndw Mavmwn Freefa'I Depth is 30 Ft) <br />WELL) SOIL BORING !Da 1-65 thratl,gh 1-87 GROUTSPEoFICA-now Bentonite 5%, Portland Cement 95% <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 />1 hereby certify that 1 am OMMIlowd to Complete this application and that 11W wort[ will be done in acCore <br />C Sen Joaquin County Ordllrtastce Codes and Standards, and otherppl <br />alcable CaMomlasts.. <br />ia <br />Signed ��— _ Title/Company Project Geologist / ECA1 <br />Print Name Chris Drabandt Date 11/16/2016 <br />DEPARTMENT USE ONLY <br />Application Accepted By: %L���= :- Date Issued: <br />Grout Inspection By/Dates: _ <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address <br />FA# ( i `a'3 L PRk t' 5 2 7 V ,3G - <br />FA PE WP Reviewed By l t/ G r , �, J, <br />Work Plan Date // <br />[3C-57 Q'C-57 Authorinkon for Other to Sign Permit P Worker's Camp ❑ WxMes Comp Waiver ❑ Entroardrrwt Permit ❑ Acari Agme-meM 0 Lead Agency Apprcval d MFR <br />CDMMENTS/CONDMONS: (Tn .t ba r h�f !✓�fY/swd� e/kuGf, NcG as �ryp�S�d na 114" <br />I <br />SR TYPE <br />PE <br />SC <br />I FEE INFO iAmT//R�/EMITTED <br />CHECKS <br />RECV'D BY <br />DATE <br />SERVICE REQUEST# <br />INVOICES <br />Work Plan <br />27 i <br />) <br />.l 7/7 — <br />�5L`>I <br />C�vr/Z <br />1214114 <br />✓W eL' 741 It / <br />Permit <br />09o5 <br />;i"? <br />,99x1 :2¢�f/7 — <br />► L91 <br />4,✓)'t <br />> ' /� <br />�'Roo7�li�z <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />