Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> 2` m ENVIRONMENTAL HEALTH DEPARTMENT <br /> N <br /> •. 1 � � 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*cehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> UON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Stockton Metropolitan AlrpGrt SOOD S Airport Way CitylStatelZip Stockton California 95206 Phone (2091468-4700 <br /> Cross Street Arch Airport Road APN 2ZZ-260-340 <br /> Property Owner* Counlyof can loanuln Phone (209)468-4700 <br /> Address _5000 5 Airport Way citylstate/zip Stockton. California 95206 <br /> C-57 Contractor MR Drilling License# - 7 97408 4 xp 0/9 Phone (714)994.0402 <br /> Address 13124 Firestone Blvd. C(ty/StatelZip Santa Fe Springs,CA 90670 <br /> Consultant/Sub-Contractor BSK ASSOCiffie3 License# _D/a Phone (559)497-2880 <br /> Address 3140 Gold Camp Drive #160 City/State/Zip_ Rancho Cordova, California 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELU13ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 20ft 40ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapar)Waler) 10 FMMMERNRWEN DIA.OFBOREHOLE 2° DUSh brobe❑MIgnPLE CASINGS❑MIAT6LEVELWELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS n/a TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 0 [1 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ONO BaingDie: n/a CnIngCia:�_CeslrigDepth: n/a <br /> ❑ INJECTION INrsoaraa omrel ❑ HANDAUGER_ GROUT SEAL DEPTH Depth of boring THEMIETYPETO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPUMPEDY ®Yes []No (Note:Mmm Reeler Depth Is30FU <br /> WELL/SOIL BORING IDs 6-21 through0-26 and 0-31 through 0-34. GROUTSPECIFICATiONS NOTE:Tfemmle used on 40fc borings <br /> Sea attached worknlan Others wille back i e v ree all, <br /> DESTRUCTION WORK TO BE PERFORMED: n/a DESTRUCTION METHOD,(CHECKALL THATAPPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of_feel <br /> WELL IOs —[I PRESSURE GROUT To depth of—feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES Fromto_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feel <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> n San Joaquin Cq y Ordinance Codes and Standards,and all other applicable California laws. j� <br /> Signed r '% _Title/Company gjyt(a�ct l C-,,eo q /e5KAW9, <br /> Print IN a 0&60—(-'}- �LTbh4 h Dale C)AIS/ZOZ: <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Dale Issued: t �� 1-ul -t -5 <br /> Grout Inspection By/Dates: 1 2, <br /> Destruction Inspection By/Dates: - <br /> FacilltvISIte Information <br /> FAName Tor.I-L�-c..'. t -0 AAddn ,0�. s FA# <br /> FA PE '� r O Wp ReNewed UO L� PR# <br /> Work Plan Date <br /> ❑C57 57AuIMdmtlonforgberloSlgn Pemiil ❑Wodeers Camp ❑Wpkere Compwe r-❑EncroadmentpenA C]AaessAgreemem LwdAgeoWApprowI MFR <br /> COMMENTSIC NDITIONS: LW-L y�W� (�.,C-�(.iw� r� Hf > I,t.( LL ()X ( ttiv�w I-v �t'l1 wy n�11= <br /> SR TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# I INVOICE# <br /> Work Plan <br /> Permit �L'qr > Ir7 .i6 $4•✓> ,( (, U�6u�l Lu <br /> V. l 7 l 33';; 11-4-23 WPOO450s8 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />