FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

DOCUSidn lnvelope ID: 38F37A80-24E9-4E5A-A643-BFI3CBA1439C �Nj,LMN ` { SAN JOAQUIN a Environmental Health Department —COUNTY Otn?� 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 2151 Country Club Boulevard City/StatelZip Stockton, CA 92504 Phone N/A Cross Street Franklin Avenue APN 123-080-30 Property Owner' 2151 Country Club LLC Phone (209) 823-1400 Address PO Box 1692 city/statelzip Manteca. CA 95336 C-57Contractor Middle Earth GeoteSting License# 899451 JY b(30[r8t5Phone (714) 633-5025 Address 23575 ChlabiOt Boulevard City/Statelzip Hayward, CA 94545 Consultant/Sub-Contractor EREY Environmental,Inc License# 643673 Phone (631)464-1634 Address 1336 Brommer Street,Suite A6 City/StatelZip santac—.cA CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsbVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 80' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN Din.OF BOREHOLE 2.W ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: El STEEL ❑PVC ❑ OTHER NA ® SOILSORING 2 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boringua: 26" Casing Dia: NA Casing Depth: NA ❑ INJECTION(4 egarge.0zars) ❑ HANDAUGER GROUTSEALDEPTH - TREMIETYPE TO BE USED: [I AUGERS [I HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEWSOILBORINGIDS CPT-lA&CPT-lB GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL We ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel belay surface if>3 feet COMMENTS: I hereby certi that I am authorized to complete this application and that the work will be done in accordance with o oar ba uin C unty Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company CEO Middle Earth Geo Testing, Inc. CF 8 OSE 1/25/2024 Print Name Amandra �t�OCk Dale Application Accepted By: A"/ )`N DEPARTMENT USE ONLY Dale Issued: 2� Grout Inspection By/Date�{¢�/lalJ�,M, 1.�/1_� , Destruction Inspection By/Dates:Facilitv/ y�,�YVI- '''''""�y�� ''' Site Information FAName � ,Q. r A FAAddress 21 t♦ rtIIIry C ULj -A# 0o $ PR# ' l�l FA PE ZQ 0 WP Reviewed By /VU I Walk Plan Date 1 /O 0 ?j 057 :51Aulhorizatlon forOther to Sign Permit ❑Workers Comp ❑Warkefs Camp Waiver ❑Encroachment Permit ❑Aeons Agreement Vhwd Agency Approval MFR CO ENf�/CONDITION : Neff, 3 hOun f� lik Gets �svr'4 pj; rer%&Pat 2 "Urs -Yw 1 lQ SWH7 ?&MI - Cnrtt- qtt 5 N � ; t'. led . I WP TYPE PE ISC I / FEE INFO AMT RENin-TED CHECK# R�ECCV'D BY DATE RMIT# INV WELL PEOICE# —d Permit Ro 313 , l�2x3 D J 3o 400 Y' s25o . $h 6§a(- 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 PWwo0.$)c EHD 29,0104-20-23 cc f'.r-5� q6 0 Site Mifigalm Wet PemutApplication -