Laserfiche WebLink
Phone (916) 760-7641 C-57 Contractor Confluence Environmental, Inc. License# 913194 <br />SANJOAQUIN <br />COUNTY-- <br />Greatness grows here <br />City/State/Zip Rio Linda, CA 95673 Address 6821 8th Street <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS CI HOSE 0 PIPE <br />Date Issued: <br />lqwt <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />114(0114 <br />, Site Mitigation Well Permit Application <br />ii.C2-3( 3 LX <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 <br />Environmental Health gepkttentetit <br />NOV 9 0vviiirk., 4 .7 20/8 <br />DS--7v4.16417AL <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION 4446-41.0, <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 574 W. Grant Line Road City/State/Zip Tracy, CA 95376 Phone <br />Cross Street N Tracy Blvd APN 233-030-010 <br />Property Owner* Ramesh Sood Phone 510-828-2266 <br />Address 574 W. Grant Line Road City/State/Zip Tracy, CA 95376 <br />Consultant/Sub-Contractor Fulcrum Resources Environmental <br />Address 517 S. Ivy Avenue <br />License# <br />City/State/Zip Monrovia, CA 91016 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />la SOIL BORING <br />INJECTION (Air Spam, Ozone( <br />El OTHER <br />WELL/ SOIL BORING Ds <br />NUMBER INSTALLATION TYPE <br /> El HOLLOW STEM <br /> El HAMMER/DRIVEN <br /> 0 MUD ROTARY <br />6 a PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 15 feet bgs <br />DIA. OF BOREHOLE 2.25" <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes El No <br />GROUT SPECIFICATIONS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: D STEEL El PVC El OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />El OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />CI MUSHROOM CAP EI 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 />Title/Company Environmental Ei Tiiii2er/Fulcrum Resources Enviionmetnal <br />Date 11/27/2018 <br />DEP T T USE ONLY <br />FA Name ii. _ 0,,,,,, Gcb; cd, rttcl FA Address 5-) 4 0 Gyv,,,As___"4 „,i FA# Q(1.)44 PR# 01-43ci Lt g <br />FA PE 2,9 ..---0 WP Reviewed By 11. -C <br />Work Plan Date <br />C-57 El C-57 Authorization for Other to Sign Permit t•frotlers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement D Lead Agency ApprovalIEKFR <br />COMMENTS/CONDMONS: (3,0 1 ,A5s ,,,„_, 'AA, Sse ii N.rcrXgdy)S irvv.4--- bre. CtlegAnneet 0.1.--4- irt. --(3...nr,,ANeoll ch <br />-VCA-p-k atiki" - C-N-a 4 11,3 AL tn-edf C.t G.,....A.A • <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 251,05- 31.5 $152 x 3 t 451 ?-s-s-isi5s- L -y 11.. 17 1 4 tile° a3cmq <br />Signed )-1042 <br />Print Name Ho Zhang <br />626-840-7843 Phone