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SAN JOAQUIN <br /> ----COUNTY` _ <br /> � lrtt. � � ' 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 Inspection <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 Lat/Long (37.9455844376/-121.320382691) �) u,f sst)�ytc)t Stockton, CA 95203 <br /> � <br /> I City/State/Zip1 Phone <br /> Cross Street W Washington Street APN Multiple APNs <br /> Property Owner* Port of Stockton Phone 209-946-0246 <br /> Address 2201 West Washington Street City/State/Zip Stockton, CA 95203 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 t. t ' Phone 707-639-7709 <br /> Address 6821 8th Street City/State/Zip Rio Linda, CA 95673 <br /> Consultant/Sub-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 /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 5 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ® HER: DPT GROUT SEAL PUMPED? El Yes El No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs 50-SO:63-SO. 6-S 70-SO:'74-SO GROUT SPECIFICATIONS neat cement <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 CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: There are multiple locations (see attached map) <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. <br /> Signed Title/Company President/Confluence Technical Services, Inc. <br /> Print Name R@1pb MQGahg Date 03/19/2024 <br /> ! DEPARTMENT USE ONLY <br /> ,� <br /> Application Accepted By: - }� �� �r Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: 'F� 72- 6'UJ <br /> Facilit /Site Information <br /> FA Name L,t J r i ; FA Address °v'-1 FA# 2z' 1�7, PR# � <br /> FA PE WP Reviewed By t, �`�'l� Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval 4,MFR <br /> COMMENTS/CONDITIONS: ilc'i� `, n��" r-� -{-� iy� �;'-�i ��1 vl v�� -� <vYt _.!(,Ird <br /> WP TYPE PE SC FEE INFO AM T REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $156x1 1Ll <br /> 1868 E. Hazelton AvenLle Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sjceh corn <br /> EHD 29-01 04-20-23 Site Mitigation Well Permit Application <br />