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SAK AQUIN Environmental Health Department <br /> COUNTY <br /> \IP, 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 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 Countyr�e.`velopment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Lat/Long(37.948846841 5/-1 21.342913758) �lU City/State/Zip Stockton,CA 95203 phone <br /> Cross Street McCloy Avenue and N Hopper 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 I 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 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 6❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION fAk Soaae.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 /> WELL/SOIL BORING IDs MG1;MC-2;MG3;MC-4;MG5;0-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 Ralph Mc ahey Date 03/19/2024 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By: � Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name flu I FA Address Ifi dl^ FA# PR# �' <br /> FA PE Gr © WP Reviewed By Work Plan Date <br /> 57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FIR, <br /> COMMENTS/CONDITIONS: <br /> LID <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHE�CK# RECV'D BY DATE WELL PERMIITT# INVOICE# <br /> Permit �05- 3 3 $ x c �� 1 Z Vp0 45` �� <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 09 468-3420 F 209 464-0138 1 www.Stcefdgco <br /> EHD 29-01 04-20-23 C C xt 1-4-Sj b R I' 6 q d Site Mitigation Well Permit Application <br />