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SAN JOAQUIN Environmental Health Department <br /> —COUNTY <br /> 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 descdbed. <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 2560 West Washington Street City/State/zip Stockton, CA 95203 Phone <br /> Cross Street South Stork Road APN 145-030-12 <br /> Property Owner*Port Of Stockton Phone (209) 946-0246 <br /> Address 2201 West Washington Street City/state/zip Stockton, CA 95201 <br /> C-57 Contractor Confluence Technical Services License# 1035255 Phone (916) 759-3512 <br /> Address 6821 8th Street City/statelzip Rio Linda, CA 95673 <br /> Consultant/Sub-ContractorOrion Environmental License# Phone (510) 525-2180 <br /> Address 2332 5th Street Suite B citylstatelzip Berkeley. CA 94710 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: OHsite BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 8ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 3.25 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> ® SOILBORING 3❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes [I No ending Die: Casing DIX. Casing Depth: <br /> ❑ INJECTION faSwae.Oonel ® HANDAUGER GROUTSEALDEPTH TREMIE TYPETO BE USED: El AUGERS ❑HOSE ❑j�IPE �+.e <br /> [IOTHER ❑ OTHER; GROUT SEAL PUMPED? ❑Yes ❑No Note:Maximum FFFtwfall Depth 130 Ft) ift. v LTV <br /> WEW SOIL BORING]Ds PSE123-01, PS823-02, PSB23-03 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL.HAT APPLY) <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ H�OSSEE`❑ PIPE1 ❑MUSHROOM CAP ❑3 feet below surface or _ feet below surface if>3 feet <br /> COMMENTS: I^e�e-wV1 <br /> or- r s roPesn� ;r g . <br /> I ersey ce Ify that I m authorized to complete this pplicatlon and that the work will a one in acco ance with S. <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed Title/Company Project Geologist, Orion Environmental <br /> Print Name Scott Stromberg Dale 318/23 <br /> DEPARTMENT USE ONLY /� <br /> Application Accepted By: Date Issued: 20 <br /> Grout Inspection By/Dates: '7i <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name rV FAAddress 'l . IA) FA# f}U� 8 PR# <br /> FA PE WP Reviewed By d IWork Plan Date 31 Zy21 v �I .,y <br /> 0 <br /> G57 C-57Au0*rizal1on for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waver ❑Encroachment Permit ❑Access Agreement Le Agen Approval R l <br /> COMMENTSICONDITIONS: �j,A6Ml� rt-s,4«'S ,(-& �E� D �-r �� G ' -" t •� ..Z 0.1 ( . <br /> i� <br /> 0o{e: Ab�f► ,�'b t Ii 0 V1312 3 W#+P(ar, QeAJ- A CaatF%dur J Sfo/F S. cotFs <br /> WP TYPE PE SC F E INFO T REMITTED CK1X DATE WELL PERMIT# n <br /> Permit os 313 $ x �... (� UJQoo 2oz3 <br /> 5Koo86t{e, <br /> 1868 E. Hazelton Avenue I Stockt , [f 4 alifornia 95205 www. <br /> sjctd.com <br /> T 209 468-3420 1 F 209 464-0138 1 www.sjd.com <br /> EHD 29-0104L1-07 . , 5cm-( 21 Slta Mitigation Well Permit Applimmon <br />