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SAN JOAQUIN Environmental Health Department COUNTY ,;, Gr en( rtrs: i;rn.'a here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliance With San Joaquin C,oI}�Q�ly Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address Lat/Long (37.94779262371-121.334474384) 1 10 r�, CltylStatelZip Stockton,CA 95203 Phone Cross Street Port Road and Stork Road APN Mulliple APNs Property Owner` Pod of Stockton Phone 209-946-0246 Address 2201 West Washington Street CltylStatelZip Stockton, CA 95203 C-57 Contractor Confluence Technical Services, Inc. License# 1035266 1 3t 2b Phone 707-639-7709 Address 6821 8th Street CltylStatelZip Rio Linda, dA 95673 ConsultanttSub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: O#site BodngsNVells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 5 to 10 it bgs ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXmACTION(VapmMater) ❑ RAMMERA)RIVEN DIA.OF BOREHOLE 2.251n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OFCASING: ❑STEEL ❑PVC ❑ OTHER ® SOILBORING _L❑ PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes []No Being Dix Cashg Dix. Csslg Depth: ❑ INJECHONWrsaaae.ozcnel ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER Ed OTHER DPT GROUT SEAL PUMPED? ❑Yes ONO (Note:Maximum Reefall Depth is 30 R) WELUSOILBORINGIDs 15SQ19S01,23 25 SO;32S634SO;42-SO GROUT SPECIFICATIONS walwallt DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feet WELL IDs ❑PRESSUREGROIIT To depth of_feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel COMMENTS: There are multiple locations(see attached map) 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with ��Saqnn Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /C6L(iA�G �-/LCaaa- LPG/_ Title/Company Presaenyconnuance recnnlcalSwvices,I�. Print Name Ralph NkGahev Date 03/19/2024 )DEPARTMENT USE ONLY 7 7 Application Accepted By: Date Issued: C D Grout Inspection By/Dates: ' Destruction Inspection By/Dales: Facillt 1Sile Information /� ) FA Name CT.w\� Ot- FAAddress ZZU (A 1;A1 IV„ FA# — � 1. FA PE Z C( SG WP Reviewed By Work Plan Date S -;> o21 CS7 ❑C57Autheballool"OthetoWPenoh ❑Workers Cmnp ❑Worwscanp Waiver ❑EnaxIwtnlPemdt ❑AcconAgreemenl ❑Lead Agency oval MFR COM NTSICON`DIT�IONS: 1") —7 T )_. L1 (�y, � (,� 1, �4-1ry`�S� LYTA r <Ii�7i11� rr11�/U`�5��/�i d(J'� c,�•i/ IY?Q �JV�ID7'Y)r '� WPJTYPE PE SC FE NFO JAMT RrMgTTEDj CHECK#I RECV-D BY I DATE WELL PERMIT# INVOICE# Permit 270 313 $ X 3ItIv fa i S i 1 -441 uci It "i 1868 E. Hazelton Avenue I tockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 N16 s)cehdYcc5IT (-3 EHD 29-0104.20.23 Site Mitigation Wet Penrlt Application