FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Permit Application 1 of 4 SAN .JOAQUIN Environmental Health Department L63T —COUNTY =+r, P Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 West of Gettysburg Place CItylState/Zip Stockton, CA 95207 Phone Cross Street Gettysburg PI and W Benjamin Holt Dr APN Property Owner* San Joaquin County Phone Address City/State/Zip C-57 Contractor Peril Drilling License# 906899 Phone 530-661-3600 Address 220 N East St City/State/zip Woodland, CA 95776 Consultant/Sub-Contractor Geosyntec Consulting License# Phone Address 3043 Gold Canal Dr Suite 100 city/statelzlp Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapoaWater) 0 HAMMERDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUG ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dla: Cning DIV. Casing Depth: ❑ INJECTION rAFeearoa.omaal ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mazlmum FKefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: /, 4 I DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED B MIST�4` I9OVER-BORE DIAMETERof10-13 inchestodepthof 5 feet WELLIDs SeeAftached t ;o $(,� ��yre 1 YAt !:f ❑PRESSUREGROUT Todepthof feel below suda2 /; P&,( Qe m ... GROUT SPECIFICATIONS Neat cement grout -3gal we -u no re a beg om of parW cement ®EXPLOSIVES S=fretbehcwsudace ��"'��111(�1+�--A TREMIE TYPE TO BE USED []AUGERS ❑HOSE )$PIPE rr� [],MUSHROOM CAP El feet below surface or feet below surface if>3 feet COMMENTS: JI q '�lC%YGt t +,) d r See list of attached wells and well information.All IDW will be hauled off by a hazardous waste certified company. .- e% I hereby certify that I am authorized to complete this application and that the work will be done in accordance with n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. - G • f `f^rJJ Signed Title/Company Project Geologist - GeosyrjterCQnsuVants Print Name Jamie Purcell Date 9/14/23 - t p,n r s 40 D ARTMENT USE ONLY Application Accepted By: Dale Issued: O� r Grout Inspection By/Dates: 102D2� Destruction Inspection By/Dates: Facilit /Site Information �f FA Name 't ,� d; FA Address ((� i C y5 u FA# otl 500 1 PR# O &I"t gJ FA PE 9 qLo WP Reviewed Bye Work Plan Dale 1.r ❑G57 -57AuffadzationforOtherto Sign Permit ❑Workers Gomp ❑Workers C=p rvr ❑Emmachmenlpennil Access Agreement Agency Approva FR COMMENTSICONDITIO*S: M W-(0SA , .M lnl /o4 A / M W- ((OIL, M uJ- 11 l A ., M W- /0 3 A , M loot-00 57A is 4la RS�ntsil ltfYe�.pl;�c. .� e�i(t+tR All ltft4iie�C -�nyn COu„fj. Rt{,tic Akr /� WP TYPE PE ) SC FEE O AMTQREMITTED CHECK# RECV-D,BY DATE I'1 WELjPEIRMIT# INVOICE# Permit qbL 13 b2 X Q �Q Vy Z W foo 901868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-013 W sj eh . Onn EHD 29oi N-20 23 Site Mitigation Well Pe rn t Application