FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Environmental Health Department —COUNTY— Greatness grows 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 County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 19104 Christopher WY city/statelzip Lathrop, CA 95330 Phone (650) 292-9062 cross street Tesla Dr. APN 198-130-20 i Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive cilyistatelzip Lathrop, CA 96330 C-67 contractor Confluence Technical Services, Inc. License# 1035255 Y,Yv I �l 2C Z Phone 707-639-7709 Address 6821 8th Street cityistatelzip Rio Linda, CA 95673 Consultant/Sub-contractor EKI Environment & Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 City/Statelzip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile BodngslWelis Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapoi/Waleil ❑ HAMMERNRWEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING O PUSH POINT(GP/CPT( CONDUCTOR CASING ❑Yes O No Boning Did: Casing Dig: Casing Depth: O INJECTION(PASoewomee) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS OHO.SE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? O Yes ❑No (Note:Maumum Freefell Depth is 30 FQ WELL/SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) - #WELLSTOBE DESTROYED 2 ®OVER-BORE DIAMETERof1010*inches to depth c28, 25*feel WELL IDs W-1,Vill ❑PRESSUREGROUT To depth of feet below sudace GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface 9>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. Coordinates (Lat, Long): (37.79266, -121 .2906), (37.79316, -121.289)* 1 hereby certify that I am authorized to complete this application and that the work will be done In accordancewilh San�Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed C Title/company Project Engineer; EKI Environment &Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 D ARTMENT USE ONLY Application Accepted By: Date Issued: I 2, Grout Inspection By/Dates: Destruction Inspection By/Dales: IIn FacilltviSito Information ^ - FAName - r LA H .t 41 - FA Address I 3CJO oW(�aAyklFA# 1 0023,E OZ PR# 0 " 'S'o FA PE 2A 5 WP Reviewed By -� Work Plan Dale O&E 'LQ L, 0C-57 G57AWprizallonforOUerlo Sign PermB OworwsComp ❑Workers Camp Waiver EnmoachmentPWft ❑AccessAgremimt AkeadAgenoyAppinivad MFR COMMENTS/C NDITIONS: , < WP TYPE PE I 22SC FEE INFO AMT REMITTED CHECK# RECV'D BY D T - WELL PERMIT# / INVOICE# Permit 31 $ItI K 7 Cc t j l ZnL U 'D 06 i 1868 E. Hazelton Avenue 1 Stockton, California 95206 1 T 209 468-3420 1 F 209 464-0138 1 SWww%c@1Tct EHO 29-0104-20-23 C4-1 q-4-0 l C)/ Site Miegaeon Well Permit ApplicaEon