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nuiM S A N J O A Q U I N Environmental Health Department Lid, —COUNTY--- - Greatness grows her SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Co ty Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address Lat/Long(37.9477926237/-121.334474384) or f City/State/Zip Stockton,CA 95203 Phone Cross Street Port Road and Stork Road APN Multiple APNs Property Owner' Port of Stockton Phone 209-946-0246 Address 2201 West Washington Street City/State/Zip Stockton,CA 95203 C-57 Contractor Confluence Technical Services,Inc. License# 1035255 ;4 p 1/ 3t Zb Phone 707-639-7709 Address 6821 8th Street City/State/Zip Rio Linda,&95673 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 5 to 10 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.25 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 7 0 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaree.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ® OTHER: DPT GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs 15-50;19-S0;23-SO;25-SO;32-SO;34-SO;42-SO GROUT SPECIFICATIONS nealcement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: There are multiple locations(see attached map) I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed i Q/L¢t1 Title/Company President/Confluence Technical Services,Inc. Print Name Ralph (cGahey Date 03/19/2024 DEPARTMENT USE ONLY Application Accepted By: '�2 ) Dale Issued: o Grout Inspection By/Dates:; Destruction Inspection By/Dates: Facilit /Site Information FA Name ��'�� 0 L FA Address L- t. W> tr)N FA# 2 Z PR# } FA PE Cr"Q WP Reviewed By j ti Work Plan Date v G57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency A roval fi3MFR 1 COMMENTS/CONDITIONS: Mc WP TYPE PE SC I FEE INFO JAMT REMITTED CHECK# RECVV''D BY f DATE q QWELL PERMIT# INVOICE# Permit c!i', .J $ z 7 ! ,'4Cs bci 1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 WV%"/.sjcehd:com EHD 29-01 04-20.23 Site Mitigation Well Permit Application