Laserfiche WebLink
SAN�JOAQUIN p <br /> � Environmental Health Department <br /> —COUNTY— <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 peril to construct andlor Install the work described. <br /> This application Is made In compliance with San Joaquin 1C�o(I ty Development Title,Chapter 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address Lat/Long (37.9455844376/-121.320382691) V V(0 I% (1/Chy/StateJZip Stockton,CA 95203 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 Clly/Statelzip Stockton,tf CA 95203 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 ,yi t 31 GL Phone 707-639-7709 <br /> Address 6821 Sib Street City/StatelZip Rio Linda,CA 95673 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/Stato/Zlp <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note. OBsile BodngsWells Require Access Agreements or Encroachment Perlis <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING IM HOLLOWSTEM BORING DEPTH 5 to 10 ft bas ❑BOLTEDTRAFRC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VOWMaler) ❑ HAMMERAIIBVEN DIA.OF BOREHOLE 2.251n ❑MULTIPLECASINGS❑MULTFLEVELWELLCASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOFCASING: ❑STEEL [I PVC ❑ OTHER <br /> ® SOILBORING r ❑ PUSH POINT(GPI CPT) CONWCTORCASING ❑Yes ❑No Baing Dia: CVAV Dla: Gasirg Depth: <br /> ❑ INJECTION Mlawroe,0z 1 ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED,. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER I ER DPT GROUT SEAL PUMPED? ❑Yes ❑No (Hole:Madmwn Freefall Depth is 30 FQ <br /> WELDSOIL BORING IDs 5050'83S0 0SO74SO GROUT SPECIFICATIONS nootcsment <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> IN WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—inches to depth of feel <br /> WELL IDs ❑PRESSUREGROOT Todepthof feetbebwsudaw <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feetbelowsudacelf>3feel <br /> COMMENTS: There are multiple locations(see attached map) <br /> I 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 President/Confluence Technical Services. Inc. _ <br /> Print Name Ra Date 03/19/2024 <br /> DE P RTMENT USE ONLY <br /> Application Accepted By: Dale Issued: 20 <br /> Grout Inspection BylDates: U A <br /> Destruction Inspection By/Dates: S Z l•Or.�l'C"1`I <br /> FacilithrISIte Information . <br /> FA Name C- S'b(' FAAddress I C.LU Iki E vv, m FA# oo '22 PR# 0 55121 <br /> �. <br /> FA PE ' cl 50 WP Reviewed By Work Plan Date <br /> C57 ❑C-57AmhodralenlmOtherlo Sign Permit ❑Warkels Comp ❑Workefs CompWaiwr ❑Ermoadunenl Permit ❑AotessAgreemenl 0LeadA9ewy al MFR <br /> COMMEN S/CONDITIONS:ry l� 1— <br /> Yrl`LS2 Z > II[ rAr� n r St �C lVit t7�`P ( l�1 rh VPS f ,c ,Uvt lY� lU rr. <br /> by (I i�d 4>< Cy . s.ibm/� �tu�SIrvp�k � � �n 'r sro_ iO)L� «HJ �s e - z <br /> WP TYPE I <br /> 7PE SC F EINFO AMTREMITTED CHECK# RECV'D BY DAAE WELL PERMIT# INVOICE# <br /> Permit 2 OJr X 3 y . ( y 2 <br /> 1868 E. Hazelton Avenue Stockton, California 46205 1 T 2099 468'314201 F 209 464-0138 www sj he. one <br /> EHD 29,0104.20-23 Site M169adm Wei Pemil ApplioNon <br />