Laserfiche WebLink
SAN 0AQUIN Environmental Health Department <br /> ( <br /> —COUNTY <br /> °a ,Fona" Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION Id <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For 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 2151 Country Club Boulevard city/Statelzip Stockton, CA 92504 Phone N/A <br /> Cross street Franklin Avenue APN 123-080-30 <br /> Property Owner* 2151 Country Club LLC Phone (209) 823-1400 <br /> Address PO Box 1692 city/State/Zip Manteca. CA 95336 <br /> C-57 Contractor Cascade Environmental License# 1058336 Phone (916)638-1169 <br /> Address 3000 Duluth Street City/State/Zip West Sacramento, CA 95691 <br /> Consultant/Sub-Contractor FREY Environmental, Inc License# 643673 Phone (831) 464-1634 <br /> Address 1336 Brommer Street, Suite A6 city/Statelzip Santa Cruz, CA 95062 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Pemdts <br /> TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING 10 HOLLOWSTEM BORING DEPTH 80' ®BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMEPoDWVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS Schedule 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPI) CONDUCTORCASING ❑Yes ®No Bobo Dia: a" Geeing Dia: 2' Casing Depth: W <br /> Ia INJECTION(AFSnrae.omrs) 1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? OYes []No (Note:Ma)dmum Freefall Depth is 30 FQ <br /> WEWSOIL BORING IDs BSW-1 GROUT SPECIFICATIONS Neat Cement <br /> M <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth o b�rp�•2S `r <br /> WELL IDs _❑PRESSURE GROUT To depth of feel below surfar� IV �QS <br /> GROUT SPECIFICATIONS _❑EXPLOSIVES From to_feet.. `�..e •�N M <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑PIPE <br /> TI HROOMCAP ❑3 feel below surface or feet belays <br /> � <br /> COMMENTS: , /f ,54- S tl I er.tg an t^_DYt-P� r'- ,.T <br /> P w olry- an c. _ WPoo ) 's2 0 <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San oaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed &etv/' Title/Company Project Manager / Cascade <br /> Print Name Matthew Tolbert Date 2/21/2024 <br /> DEPARTMENT USE ONLY JJ// <br /> Application Accepted By: Dale Issued: Z 12 2 02TT <br /> Grout Inspection By/Dat ?. <br /> Destruction Inspection By/Dates: <br /> Facllf /Site Information - 1 <br /> FAName 'g D u e—J P. V I FAAddroas I ( COUL46 -A# I 0C)q 3g3 1 PR# Q t}r6�F6 <br /> FA PE Z WP Reviewed By V4j Work Plan Dale 0�j0/$4p3 'I'' �& <br /> ❑C57 G-57 Authodutlan for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment ermit ❑Access Agreement ❑Lead Agency Approval p+crrc r <br /> COM ENTSI ONDITI S: • r. I'1M) (.J S f .5 cit'k _r i <br /> l; �, com��� ,L ''e�e.(u��z�►a cess f� <br /> Ft�r �Xa � f' Z <br /> rtYalAl r'r! _ m s JG(QIQ wta�� cw,e,- •� ass. Y�'t r-f-cabers r Kea, r <br /> WP TYPE PE SC FEE INFO AMT REeM7ITTED CHECK# RECV'D BY i DATE (WELL PERMIT# INVOICE# <br /> Permit QD( 3 - $162x ` �.` /� { 3 2 WFoo 4 5 291 <br /> 1868 E. Hazelton Avenue ^` -'•'"" California952V n " I 'wwwc.$)cehd c^ <br /> l <br />