WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN 'J O A Q U I N Environmental Health Department COUNTY 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 1120 West Hammer Lane City/State/Zip Stockton, CA 95209 Phone Cross Street Thorton Road APN 07749027 Property Owner* Knowles Family Irrevocable Trust, Carl Knowles - Trustee Phone Address PO Box 640 City/State/Zip Woodbridge, CA 95258 C-57 Contractor Doulos Environmental, Inc. License# 730042 Phone 916-990-0333 Address PO Box 2559 City/State/Zip Orangevale, CA, 95662 Consultant/Sub-Contractor Tylor McMillan's Well Service, LLC License# 9201 Phone 916-761-5224 Address 9530 Hageman Rd. Suite B#349 nrv, .,, f!� City/State/Zip Bakersfield, CA, 93312 7 V I t, s- CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElINJECTION(Air Sparse,Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 15 ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs see comment box below $ ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ® EXPLOSIVES From 100 to 20 feet below surface TREMIE TYPE TO BE USED ❑AUGERS ® HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet Well IDs: MW-1, MW-2, MW-4, MW-9, MW-1OD, MW-11, MW-12, and IW-1A/B through IW-4A/B (Wells IW-1A/B through IW-4A/B are nested wells; 2 well casings in each borehole) 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 Codes and Standards, and all other applicable California laws. Signed �� %�'G,q� Title/Company Stratus Environmental, Inc. Print Name Steven Mok Date 5/23/23 .,DEPARTMENT USE ONLY / Application Accepted By: Date Issued: C ( C Grout Inspection By/Dates: Destruction Inspection By/Dates: 4 y- Facilit /Site Information FA Name A Address A# PR# oe FA PE WP Reviewed By L Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit 2a('jZ cc ,� ©o Wevt 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 20�-0138 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application