FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN Environmental Health Department —COUNTY— Greatness grows here. 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 County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 17400 Golden Spike Trail city/state/zip Lathrop, CA 96330 Phone (650) 292-9062 Cross street Towne Centre Dr. APN 191-350-04 Property ownee City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive ciWstate/zip Lathrop, CA 95330 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street city/state/zip Rio Linda, CA 95673 Consultanusub-contractor EKI Environment&Water License# N/A Phone (650) 292-9100 Address 2001 Junloero Serra Blvd Ste 300 City/State/Zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NU MBE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaWfflater) 0 HAMMERNRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OR ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Oia: Cwing ON: Caslrg Depth: ❑ INJECTION W,Saeoe Ozw1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefell Depth is 30 FQ WELIJSOILBORING IDS GROUTSPECIFICATK)NS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL IDS MWM-27 O PRESSURE GROUT Todeplh of 24 feel below surface GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feel below surface or feet below surface d>3 feet COMMENTS: Coordinates (Lat Lon ) p g): (37.8047, -121.3107 . The mushroom cap will be excavated 22 inches wide and 3 feet below surface. 1 hereby certify that 1 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 �lmisr�lUio��arceat� Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 - DEPARTMENT USE ONLY Application Accepted By: Date Issued: ( 4 td-e Grout Inspection By/Dates: Destruction Inspection By/Dates: .. Faclli /Site Information V FA Name MW FA AddressCip ' FA# (gip L..3 ,� �� PR# p 1-q I FA PE WP Reviewed By -T Work Plan Date 2.o Z- 0G57 C-"AuIhDrzalionror Olherto Sgn Pemgl ❑workers Carp ❑Workerscompwalm Emoadment Peand ❑AaessAgmeomt eae AgemyApproval MFR COMMENTS/C ND IONS: WPTYPE PE I 2SC FEEINFO AMT REMI-TTTED CHECK# RECV'D BY AT WEL�LLPERMIT# INVOICE Z # Permit 0 Z J B 1 �� `, C. I 1868 E. Hazelton Avenue I Stockton, Califor is 952 5 1 T 209 468-3420 1 F 209 464-0138 1 w�ww.sjcehd.com EHD 29-0104-20-23 1 I'2.� I D� site Mittaton Wet Permit Applirabon