COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

�2'oPnc° SAN�JOAQUIN Q Environmental Health De artment . .: —COUNTY— REE \ `�� / m �q k,FOaa�P' Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and RemediatiE0%7ROh'"EN„qL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pERRjjT/SERV,/-ES 48 Hours Advance Notice Required For All Inspections 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 San Joaquin County Well Standards. Job Address 1501 S.Airport Way CityJState/Zip Stockton,CA 95204 Phone 209-951-8228 Cross Street Airport Way &list Street APN 169-020-11 Property Owner* City of Stockton Phone 209-937-8539 Address 400 E.Main Street,4th Floor City/State/Zip Stockton,CA 95202 C-57 Contractor Advanced GeoEnvironmental,Inc. License# 680557 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor A.G.E. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton/CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10',20',50' ❑BOLTED TRA C BOX ❑STOVE PIPE El EXTRACTION(Vapor/Water) [:IHAMMER/DRIVEN DIA.OF BOREHOLE 2-inch []MULTIPLE ASINGS❑MULTI-LEVEL WELL CASING DIA na ® SOIL VAPOR PROBE 8 E] MUD ROTARY CASING THICKNESS na TYPE OF C ING: ❑STEEL ❑PVC ❑ OTHER na ® SOIL BORING 4 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [IYes ®No Boring D' . na Casing Dia: na Casing Depth: na ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 10',20',50' TRE I TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROL Y SEAL PUMPED? ❑Yes E No (N e:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SV2(ABC),SV3(ABC) GROUT SPECIFICATIONS Portland pe II SV4(ABC) SV5(/SBC) DESTRUCTION WORK TO BE PERFORMED: DESTRUC ION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED ❑OVE ORE DIAMETER of inches to depth of feet WELL IDs ❑P SSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ CPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE MUSHR00M CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: See attached Site Assessment Work Plan I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Coffes and Standards,and all other applicable California laws. A / Project-Manager/A.G.E. A Signed AN1A�( a L� Title/Company Print Name Timothy J.CL911an Date 08/02/2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name19Q FA Address (.�� S � . 4� FA# Qa'lci'1q PR# t FA PEn'�A> WP Reviewed By fit_ Work Plan Date �� p It-57 ❑C-57 Authorization for Other to Sign Permit 'Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agenc pproval [DMFR COMMENTS/CONDITIONS: \ WP TYPE PE SC I FEE INFO JAMT REMirrEDI CHECK# RECV'D BY j DATE j WELL PERMIT# j INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 ( Z`'�(,; Site Mitigation Well Permit Application L �..�1i3� S (fr�> �`� L'iL`