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0 <br /> 6 <br /> Z\ SA N.J OAQ U I N Environmental Health Department <br /> " '! h `� COUNTY <br /> ``Q�ct�_�`P' Greatness nrotvs 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 my Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Lat/Long(37.94 5 5 844 3 76/-1 2 1.320382691) Co4*4 City/State/Zip 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 City/State/Zip Stockton,CA 95203 <br /> C-57 Contractor Confluence Technical Services,Inc. License# 1035255 *%gt n t 3(1Z L 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 WELLIBORING 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 /> ® SOIL BORING 5 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarce.Ozone) ❑ 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 /> WEW SOIL BORING IDs 50-SO;63SO;66-SO;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 /> Signed7eeo� Title/Company President/Confluence Technical Services, Inc. <br /> Print Name Ralph McGah y Date 03/19/2024 <br /> DEPARTMENT USE ONLY <br /> _ n n <br /> Application Accepted By: �'�/ Date Issued: 20 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name t,t,, C+ FA Address , FA# PR# �3 ,5 IF <br /> FA PE ' q 50 WP Reviewed By '--Y kAJ Work Plan Date <br /> G57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency A proval MFR <br /> COMMENTS/CONDITIONS: , <br /> YYt c�S� 2 � 4ifi Qctr Ivt(���r <br /> by d a e-r�cy S.1 b 04— ►�s"4 AS /rert,� +0 f-c 2 Fr sTp, �' 1 L -;ve <br /> WP TYPE PE Sc F E INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PER(MMII(T'#) INVOICE# <br /> Permit 2 OS X Vv N l '!- l v <br /> 1868 E. Hazelton Avenue Stockton, California 55205 I T 2099 468 3420 1 F 209 464-0138 1 www.stcend.cor� <br /> EHD 29-01 04-20-23 Site Mitigation Well Permit Application <br />