FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

op6u)N\ IN' °�� SANA OAQ U I N Environmental Health Department COUNTY qci�-Fioa��P>/ r, t 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 ty Dev I)pment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address Lat/Long(37.9477926237/-121.334474384) ro� City/State/Zip Stockton,CA 95203 Phone Cross Street Port Road and Stork Road APN Multiple APNs Property Owner* Port of Stockton Phone 209-946-0246 Address 2201 West Washington Street City/State/Zip Stockton,CA 95203 C-57 Contractor Confluence Technical Services,Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street City/State/Zip Rio Linda,&95673 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bodngs/VVells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 5 to 10 It bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 7 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION Wrsoarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ® OTHER: DPT GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING Us 15•SO;19-SO;23-SO;25-SO;32-SO;34-SO;42-SO GROUT SPECIFICATIONS neat cement 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 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [--]AUGERS [:]HOSE [:]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: There are multiple locations(see attached map) I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company President/Confluence Technical Services,Inc. Print Name Ralph NfcGahey Date 03/19/2024 DEPARTMENT USE ONLY Application Accepted By: /— I __ _ _Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name t� vl C C FA Address `Z 20 1 W A t7y^ I FA# Z 2 PR# I FA PE G'( WP Reviewed By J Work Plan Date 5 v G57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑LWorker'ss Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency A proval MFR C�M NTS/CONDITIONS: Z 1 &-k- Cc',r cat �M'S17 i� C`ti�jj<�` "►^ r,l'1�1j.� i�d . (jt^ � t�� a �'� �YN\c 5�� II?�r"l re&,4�sCCIn slL � WP TYPE PE Sc F NFO AMT REMITTED CHECK# RECV-D BY (DATE pWELL PERfMIT# INVOICE# Permit 776130 $ X 7;!:� 0 t--Q b q '+6 1P__00 C1 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 Sjce�hd:C m EHD 29-01 04-20-23 Site Mitigation Well Permit Application