Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton 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 <br />Cross Street <br />2804 East Fremont Street <br />North Shasta Ave. <br /> <br />City/State/Zip Stockton, CA 95205 Phone <br />APN 143-430-08 <br />(209)946-0233 <br /> <br />Property Owner* Diesel Performance Inc. <br /> <br />Phone (209)946-0233 <br /> <br />Address 2804 East Fremont Street City/State/zip Stockton. CA 95205 <br />C-57 Contractor TEG <br />Address 11350 Monier Place <br />Consultant/Sub-Contractor ATC Group Services, LLC <br />Address 1117 Lone Palm Avenue, Ste. 201B <br />License# 706568 Phone (916) 853-8010 <br />City/State/Zip Rancho Cordova, CA 95742 <br />License# Phone (209) 579-2221 <br />City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />EXTRACTION (Vapor/Water) <br />EI SOIL VAPOR PROBE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />BORING DEPTH 20 ft. El BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 2 in. El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />SOIL BORING 4 18:1 PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparqe, Ozenel El HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs SB-101. SB-102. SB-103. SB-104 <br />CONDUCTOR CASING D Yes IZJ No Boring Dia: Casing Die: Casing Depth: <br />GROUT SEAL DEPTH 20 ft. TREMIE TYPE TO BE USED: El AUGERS 0 HOSE PIPE <br />GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freetall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Neat cement <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED Ei AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of <br />El PRESSURE GROUT To depth of <br />0 EXPLOSIVES From to <br />El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />inches to depth of <br /> <br />feet <br />feet below surface <br />feet below surface <br />COMMENTS: The soil vapor probe will be installed first to approximately 5 feet bgs and after vapor sample collected and associated tubing <br />removed, the soil boring v,,111 be advanced through the same bore hole to approximately 20 feet bgs. <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />_aan Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company 7---.--toogr3tfr-i-A...1 aA-LiOal"-)6A C <br />-- Print Name Date 5 e-5- <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issue: G <br /> <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name bi. e Se 4 co"4"<-1- 7,---,-. FA Address 2-8 `=-4 ir:•`-'3.-V 4-rco....-.) •"--4" 153/4- FA# 00 2_4 on P. viii ici 1,4 <br />FA PE 2-c1C-0 WP Reviewed By L ...( Work Plan Date g/-25- ..o , i <br />0 C-57 ID C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval ID MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit Z.,i 0 c -3 a 3 $139x 3 I 4 -1 ) 1 a /Su c L -X (0(-4. (i 7 Sg.oa-rnel 1 <br />e 2itO3 5-2-3 t I3X 3 <br />EHD 29-01 10-26-2015 <br />617,4, —) 5i:_oo.-717g9 <br />Site Mitigation Well Permit Application