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i <br /> S A N J O A Q U I N Environmental Health Department <br /> '�a'I'.� COUNTY <br /> Grentress nr-rtvs 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 County )Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Lat/Long(37.9455844376/-121.320382691) 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 Phone 707-639-7709 <br /> Address 6821 Bin 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 BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ® HOLLOW STEM BORING DEPTH 5 to 10 it bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN 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 soarne.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 5(SO;63-SC;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 /> Signed Title/Company President/Confluence Technical Services, Inc. <br /> Print Name Ralph McGah Y Date 03/19/2024 <br /> I 1` 1 VDEPARTMENT USE ONLY <br /> Application Accepted By: J Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: D1v\ SII?i� <br /> Faciltt /Site Information <br /> FA Name I cyy1 FA Address I VV'� yk, - fcfyj FA# UU �� PR# �h­ <br /> FA PE `�C( r�L) WP Reviewed Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval [ MFR <br /> COMMENTS/CONDITIONS:] I)6.-t- Pc1rk "-C. t Eyt r kk v"'j�---f;�c ,eA ! r tt,f tea <br /> d �L:� s�t b r ►�suks/Mork �4 S �� <br /> WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit �q/ I ' / /A0 0"5+1-0111 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468t-3420 F 209 464-0138 wvvv`v sjceh comb <br /> EHD 29-01 04-20-23 Site Mitigation Well Permit Application <br />