Laserfiche WebLink
Signed <br />Print Nam <br />fi— <br />Josh Kerns Date 8/9/17 <br />certify that I am authorized to complete this application and that the work will be done in accordance with <br />an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Confluence, Inc. <br />I here <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: xqz ‘143. ti <br />--)1 c,Ls P 11 2,1 <br />DEPAfrrMENT USE ONLY <br />SAN JOAQuIN <br />COUNTY — <br />Greatness grows here <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All 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 />City/State/Zip Lathrop, CA 95330 <br />Phone <br />ApN 191-220-13 <br />Job Address De Lima Road <br />Cross Street South Manthey Road <br />Property Owner* Saybrook CLSP, LLC <br />Phone (650)632-4522 <br />Address 303 Twin Dolphin Drive, Suite 600 city/state/zip Redwood Shores, CA 94065 <br />C-57 contractor Confluence Environmental, Inc. License# 913194 Phone (916)760-7641 <br />Address 3308 El Camino Ave, Suite 300 #148 city/state/zip Sacramento, CA 95821 <br />Consultant/Sub-Contractor HydroFocus, Inc. License# Phone (530)759-2484 <br />Address 2827 Spafford Street <br /> <br />City/State/Zip Davis, CA 95618 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 24 ft D BOLTED TRAFFIC BOX MI STOVE PIPE <br />DIA. OF BOREHOLE 10 in 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL EN PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes IN No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: LE AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? U Yes 111 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS neat cement sanitary seal - 10 ft <br />additional 2 ft bentonite transition seal below sanitary seal <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />CD MONITORING 1 El HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING PUSH POINT (GP/ CPT) <br />INJECTION (Air Spam, Ozone) 0 HAND AUGER <br />OTHER OTHER: <br />WELL/ SOIL BORING IDs CLSP-12 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs <br />GROUT SPECIFICATIONS <br /> <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br /> <br />TREMIE TYPE TO BE USED 1:1AUGERS Ell HOSE 0 PIPE <br />COMMENTS: <br />FA Name i.-C41061-1 %-e6"4'.4644.- <br />Ce,A%4--k tAlvwf <br />FA Address Z.. 1-8,16-4.... r......04 FA# 06)234 Lci. io PR# OS9 .7 , <br />Li C....did <br />FA PE e...,1A0 c WP Reviewed By L ----,X Work Plan Date \A, 1 t_.e i IA,.., <br />If'C'57 0 C-57 Authorization for Other to Sign Permit 121(orkees Comp 0 Workers Comp Waiver 0 Encroachment Permit 111(rcess Agreement 13'<ad Agency Approval PleR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 'p,i140 1 313 $152x 1 $ LS)- VII5 1----')( %114iii Wf00-3 .119i <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.conn <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application