Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> —COUNTY <br /> `a,,,1ovlo- Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For 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 /> Job Address 17100 Golden Valley Pkwy(Let:37.80589, Long:-121.2986) City/State2lp Lathrop, CA Phone (650) 292-9062 <br /> Cross street Towne Centre Dr. APN 191-190-49 <br /> Property Ownee City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cityistateizip Lathrop, CA 95330 <br /> C-57 contractor Confluence Technical Services, Inc. License# 1035265 Phone 707-639-7709 <br /> Address 6821 8th Street cityistate/zip Rio Linda CA, 95673 <br /> ConsultantfSub-contractor EKI Environment&Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/state/zip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapaAYater) ❑ HAMMER(DRIVEN DIA.OF BOREHOLE O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI GPT) CONDUCTOR CASING ❑Yes ONO Boling DM: Caskg Dia: Casing Depth: <br /> ❑ INJECTION(MSxoe.Ozone] ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Manmum Freefal Depth Is30 FQ <br /> WELUSOIL SORING IDS GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 [1 OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS MwM-12 ®PRESSURE GROUT To depth of 21 fcelbelowsurface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 inches wide and 3 feet below surface. <br /> 1 hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> �+ San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> DEPARTMENT USE ONLY � <br /> Application Accepted By: Date 11 sued: A <br /> Grout Inspection By/Dales <br /> Destruction Inspection By/Dates: <br /> F till /Site Information aqo t) _ <br /> PR# <br /> FAName [2. M FAAddiess ,3 Q(,(TA0-- FA$ 00 - 35s Z p -10D <br /> FA PE ✓'� WP Renewed By - Work Plan Date 0 -{ 2S <br /> ❑C57 G57AWlodzaConl"OalerklSlgn Pema ❑Wakees Gaup ❑Workets Carp Waiver OlEnciactinientPerift ❑, a Agmemenl Lead Agency Approval FR <br /> COMMENTSIC N ITIONS: <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY ATE 1 WELL PERMIT# INVOICE# <br /> Permit 2gp'Z 3 � U- SU) li 11p W�'oo 5052 <br /> 4-75 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-013851 www sjcehd.com <br /> EHD 2"1 04-20-23 Site Miaaaaon Well Permit Applimbon <br />