AP2400573 (4) - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DER!' FTIOENT NOV 18 2015 • `•� 1868 Hazelton Avenue, Stockton, CA 95'0::3-6232 E��V11� i ©NMEN7- .::-.:. Telephone: (209) 468-3420 Fax: (209) r468-3433 .'Ieb. www.s�cehd.corn �� iIEA��H �r F otiz�. - RM1T/RERvICEs SITE MITIGATION WELL & BORING PEF;;NII'r APPLICATION For Wells and Borings Used for Contaminant Invest 3ati Dins and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRIAV CATE ISSUED Application is hereby made to San Joaquin County for a pelTnit to constru a)d')r install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter_l 1 1'i.3,and the San Joaquin County Well Standards. Job Address +91c7chr;s;opherwaylas-I, City/'StatelZip Lalhrcl CP95: o Phone Cross Street Nasne Way APN P rope rtyOwner• Bua2OnleslLC.aCalibmia6mledlab9-iyoompany (Can�ad ImyE51aGo! Phone 1916I379-3890 Address 8515 Elder Cmek Road -7� �irr.,�:11 ��'. �!•'<"i'�`�l City/State/Zip s-- nlc C),85828 C-57 Contractor All Well Abaadonmerl "r, License# 848359 Phone oiromi- m Address 37e9Flzgarald Road City/';tatejZip Rena-.:mlovi CA e37a2 Con sultantlSub-Contractor HydmFaws.Inc. License# Phone I5311)r5e-2484 Address ze27sparrurdsrreel C Ityl:itatelZip Dam, :k951Y'. CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsMlelis Require Acce :.Fgr:•ements or Encroachment Permits ]L TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOL D''RFI7IC BOX ❑STOVE PIPE ❑ EXTRACTION(VaperlWater) ;] HAMMERlDRIVEN OIA.OF BOREHOLE ❑MUL I I7LI C.ISINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE 0'' ;&;IN. ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Bering pi; _ Casing Dia: Casing Depth' ❑ INJECTION lArSporna,0z"I ❑ HAND AUGER GROUT SEAL DEPTH TREMIE I'PE To BE USED' ❑AUGERS ❑HOSE ❑PIPE © OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mi nu n Fleefall Depth is 30 FI} WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHt:_]; CrIECK ALL THATAPPLY) #WELLS TO BE DESTROYED l 0 OVER-HORE C rMET:R of 0.5 inches to depth of 33 feet WELL IDS KMw-1 ❑PRESSJRE GROUT Tndeith if feel below surface GROUT SPECIFICATIONS neatcamenl ❑EXPL0:31VES F I;m_—to feet below surface TREMIE TYPE TO BE USED ❑AUGE RS ❑HOSE *PIPE ❑MUSHF OOM CAP [,1 3 ees below surface or feet below surface if�-3 feet COMMENTS: v� I hereby certify that I am authorized to complete this application and that tt= A orl.will be done in accordance with Sa4001 fiance Codes and Standards,and all ott :r apl.licable California laws. Signed Title/Company new®I !rurion-re=u Print Namo �y k S c� Date— DEPARTMENT USE ONLY Application Accepted By: {UVC� �v�-G�'��G'��'+ I)a:e Issued: Grout Inspection By/Dates: Destruction Inspection Ay/Dates: FacilitviSite Information FA Name FA Address 'AP PR# FA PE WP Reviewed By __ Work Plan Date ❑C•57 ❑C•57 Aulhonzalion ler ol1e to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachme l Ps mi ❑Access Agreement []Lead Agency Approval ❑MFR COMMENTSICONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RI°CV'D BY Dr 1T1: SERVICE REQUEST# INVOICE# Work Plan Permit 2')C 2- 50 j $1130 x I S.�oU 73 Ja`o 3 EHO 29-01 6-23-2015 Site Mitiqation Well Permit Application