FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Department Environmental Health De 4 ._. COUNTY- — �`,FOR � 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 Rio Blanco Road City/State/Zip Stockton, CA 95219 Phone Cross Street Rio Blanco Road APN APN 06661005 Property Owner* Stockton Westlake Investments Phone 209-478-7954 Address 10100 Trinity Parkway, 5th floor City/State/Zip Stockton, CA 95219 C-57 Contractor PeneCore Drilling TS 7 License# 906899 A ;D II / /Z� Phone (530) 661-3600 Address 220 N East St City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor Geosyntec Consultants Inc License# Phone (916) 205-6833 Address 3043 Gold Canal Drive, Suite#100 City/State/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 4 ® HOLLOW STEM BORING DEPTH 20 to 40 ft bgs ® BOLTED TRAFFIC BOX ®STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparcle.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs See Attached GROUT SPECIFICATIONS Neat cement grout - 3gal water to one 471b bag of portland cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [—]AUGERS ❑ HOSE [] PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: T 61 I hereby certify that I am authorized to complete this application and that thew will be done in accdr ance with I San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Company Scientist, Geosyntec Consultants 61, Print Name Jennifer Martin Date 3/22/2024 I Application Accepted By: C DEPARTMENT USE ONLY Date Issued: 1 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name /� FA Address C`tt jr ` ' TA# PR# (✓/ LlgJ FA PE G' WP Reviewed By /. Work Plan Date QZ ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement ❑ Lead Agency Approval �kMFR COMM{ENrT-�S/C NDITI NS: I , t t , v riot - c� ) wellO .1 aKa M� deS- o �- -�c � � �c k tv Usk: ,hj nli � WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit �0( $162 x �j '-� i �) (}, (,f l� �r p 1868 E. Hazelton Avenue Stockton, California 95�d5 j T 209 468-3420 1 F 209 46 01 8 1 www.sjcehd.com EHD 29-01 7-01-2023 Site Mitigation Well Permit Application