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a <br /> S A N J O A Q U I N Environmental Health Department <br /> " I ---COUNTY--- <br /> c'trtron'`` Greatness (/rows her, <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 Countcy�jDe`velonment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Lat/Long 37.9412405788/-121.319257485) ,V/ City/State/Zip Stockton,CA 95203 Phone <br /> Cross Street APN Multiple APNs <br /> �9 Property Owner* Burlington Northern and Santa Fe Railway Phone 901-495-3778 <br /> Address ( (.7 44f W,, l J 4 V C, .) City/State/Zip Qp LEM <br /> C-57 Contractor Confluence Technical Services,Inc. License# 1035255 Z, Phone 707-639-7709 <br /> P�-3Address 6821 8th Street City/State/Zip Rio Linda,6A 95673 <br /> �o jtCi 1,ConsultanVSub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ® HOLLOW STEM BORING DEPTH 5 to 10 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> El SOIL BORING 7 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sen..Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ® OTHER: DPT GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is 30 Ft) <br /> WELL/SOIL BORING IDs 90-S0:96SO;103-S0;109-S0;115-SO; GROUT SPECIFICATIONS neat cement <br /> 122-SO;130-SO <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM GAP 3 feet below urface or feet below surface if>3 feet <br /> COMMENTS: There are multiple locations(see attached map) yr..Lr old Y, <br /> I hereby certify that I 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. 5 <br /> Signed E Title/Company President/Confluence Technical Services Inc. V _ <br /> Print Name d Date 03/19/2024 �_ l.(r' <br /> i� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Z7 = Date Issued: <br /> Grout Inspection By/Dates: <br /> i14r <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name �yt� FA Address ? BLS i _1�11 FA# 0 22Z PR# e)')? <br /> FA PE I?Cl 50 WP Reviewed By — fir`; Wark Plan Da 2-02 <br /> C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit t tj Lead Agency Approval <br /> COMMENTS/CONDITIONS: fil 7 % -� <br /> S A, <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY ///I DA E WELL PERMIT#++ ll INVOICE# <br /> Permit Y <br /> 1868 E. Hazelton Avenue f Stockton, California 6t05 1 T 209 468 340 1 FJ 209 464-0138 1 www.sjcehd.corri <br /> EHD 29-01 04-20-23 Site Mitigation Well Permit Application <br />