Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> 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 County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job address 19104 Christopher WY cityistate/zip Lathrop CA 95330 Phone (650) 292-9062 <br /> Cross street Tesla Dr. APN 198-130-7o \ (%) <br /> Property Owner& City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive city/State/zip Lathrop, CA 95330 <br /> c-sT contractor Confluence Technical Services, Inc. License# 1035266 ZA 1 /31 10"b phone 707-639-7709 <br /> Address 6821 8lh Street city/state/ztp Rio Linda, CA 95673 <br /> Consuitant/Sub-contractor EKI Environment &Water License# NA Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/State/zlp Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: O#site Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporM/ater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Bain Dia: Casing Dla: Casing Depth: <br /> ❑ INJECTION(Arsmae.Dzmel O HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TORE USED: OAUGERS ❑HOSE ❑PIPE <br /> O OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madmim Freefall Depth is 30 FI) <br /> WELU SOIL BORING JOS GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 ®OVER-BORE DIAMETER OM O 10'inches to depth of28, 25*1eel <br /> WELL IDS W-11,W-2' ❑PRESSUREGROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feet below surface >3 feel <br /> COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. <br /> Coordinates (Lat, Long): (37.79266, -121 .2906), (37.79316, -121 .289)* <br /> I hereby certify that I am authorized to complete this application and that the work wl11 be done in accordance with <br /> San qJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �l4ZhGCG/ZLC¢�i �9/LeOLLL Title/Company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> FacilitwiSite Information q <br /> FA NameVkAuv W . .t F - FAAddress I ,—> 0 -roVjn FA# 1 0023 z PR# o 5 <br /> FA PE �(� !D WP Reviewed By Work Plan Date C-L 2D L <br /> 0C-57 C57AUthWzadWlorOtherto Slgn Pemlh ❑workers Camp ❑Workers Carp WaIw En=ixhmentPemb OAmessAgreemenl Lead AgemyAppmva OMFR <br /> COMMENTSIC NDITIONS: I <br /> s ferM�� Cov�rs Z hn,.rs 0 pirvrik tlnr�ec{ <br /> WP TYPE I PE I SC I FEE INFO AMT REMn­TEDj CHECK# I RECV'D BY D T - WELL PERMIT# INVOICE <br /> # <br /> Permit 31 slU K t cc- I I ZOL D �J o( 1�f <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s cewacofn`� C' <br /> EHDn,0I N.M.23 Site MiEgation Well Permit Application <br />