Laserfiche WebLink
j) <br /> r'9w";i-y <br /> SAN JOAQUIN COUNTY <br /> ICY ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 13 3 <br /> Id <br /> 1868 Hazelton Avenue, Stockton, CA 95205-623 2 OCT 210'91TE MITIGATION <br /> UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si -F-- "' "'_qov.o T <br /> WELL & BORING PERMIT APPLICAT <br /> Ik MiTIAER VICES <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-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 wank described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115,3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 1501 D'Arcy Pkwy Cross Street Howland City/State Lathrop,CA Zip 95330 APN 198-13-032 <br /> Property, Crossroads L.P. Address 3000 Lava Ridge Court,Suite 115 CitylSt,te Rosevilie,Ca zip-L5561 Phone (916)782-3330 <br /> C-57 Contractor Gregg Drilling and Testing Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone (925)313-5800 <br /> Consultant/Sub Cntr Hydro Focus,Inc. Address 2827 Spalford Street City/State Davis,CA Lic Phone (530)759-2484 <br /> Billable Party Hydro Focus,Inc. Address P.O.Box 2401 City/State Davis,CA 7ip­95611 Phone (530)759-2484 <br /> GIS Coordinates:X .37.B0041 y-121.28369 _ 1 <br /> 3 74c(b," - I 1121ica- <br /> CONSTRUCTION WORK TO BE PERFORMEE�. <br /> RM NEVVWELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 0 SOIL BORING IDS <br /> N WELL IDS KMW-8 <br /> EI OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> F11 MONITORING 9 HOLLOW STEM DIA.OF BOREHOLE 8 E]MULTIPLE CASINGS[:]MULTI-LEVEL WELL CASING DIA: 4" <br /> —0 EXTRACTION:Vapor/Water El HAMMER/DRIVEN CASING THICKNESS Srh 40 TYPE OF CASING: El STEEL 9 PVC. C] OTHER <br /> —El SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL 10 TREME TYPE TO BE USED: D AUGERS El HOSE 0 PIPE <br /> —0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes A No(MAXIMUM FREE FALL DEPTH IS 30 Fir) <br /> 171 INJECTION(i.e.MrSparge Ozone)El HAND AUGER GROUT SPECIFICATIONS neat cement <br /> —E]OTHER: — 0 OTHER: APPROX.BORING DEPTH 30 El BOLTED TRAFFIC BOX OR 9 STOVE PIPE <br /> COMMENTS: See Jocaton map&proposed can5tr"Vun fit workpian CONDUCTOR CASING 0No EI Yes:Casing Dia:_Casing Depth:_ Boring Dia- <br /> NOTE: OFFSITE WELLS Sr BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 4 #OF WELL(S)TO BE DESTROYED 9 OVER-BORE DIAMETER OF 7 il")&R(7)INCHES TO DEPTH OF 15,20,25 FT <br /> WELL IDS: PZ-1,PZ-2,PZ-3,PZ-4 El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS neat cement El EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[:1 AUGERS El HOSE X PIPE ❑ MUSHROOM CAR AT(>3 FT— —FT BELOW SURFACE <br /> COMMENTS see location map and well permits In workplan <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable Calico i.I <br /> Signed . Qtlt�"MZCL Title/Company Assistant Hydralogist/HydroForus,Inc. <br /> Print Name Christina Lucero Date 1 0 12 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 15-01 f6e-K-110,41 <br /> WORK PLAN DATED &,t6-Lt5T-9,-2I <br /> J <br /> APPLICATION ACCEPTED BY - la Wl <br /> - <br /> DATE ISSUED AREA 1417] <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CO NDITIONS: <br /> ACCOUNTING ONLY: AID ff FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVrD BY DATE SERVICE RO* INVOICE <br /> REQUEST PR# <br /> Qf r) <br /> 130 x 10 3 SR4 707ZCD <br /> R%# 7C)72-/ <br /> (3500) <br /> zv(' <br /> 22 3 a. 4 3 <br /> C-57 — WC ✓ WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG AlilJ <br /> EHD 29-01 7IY4-1-14 WELL PERMIT APP <br />