Laserfiche WebLink
SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> `A IL,,.W 10" Greatness grows here. <br /> - <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 De Lima Rd (Let, 37 83500 Long, -121 2916) City/State2lp Lathrop CA Phone (650) 292-9062 <br /> Cross Street Manthey Rd APN 192-020-66 <br /> Property Owner' City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive City/Statelzip Lathrop, CA 95330 <br /> C-67 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street city/state/zip Rio Linda, CA 95673 <br /> ConsultantfSub-Contractor EKI Environment& Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junivero Serra Blvd Ste 300 City/Statelzlp Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> O EXTRACTION(Vep Hater) ❑ HAMMERrURIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> O SOILVAPORPROBE O MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL OPVC O OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes ONo BaSg Die: Casing Ole: Casing Depth: <br /> ❑ INJECTION(Ak eoaraao. ❑ HANDAUGER - GROUTSEALDEPTH TREMIE TYPE TO BE USED: OAUGERS ❑HOSE OPIPE <br /> ❑ OTHER O OTHER GROUT SEAL PUMPED? OYes ONo (Note:Maximum Freerall Depth is 30 Fit <br /> WELUSOILBORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of Inches to depth of feet <br /> WELLIDs CLSP-12 ®PRESSURE GROUT To depth of 24_feel below sudace <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ®PIPE ❑MUSHROOM CAP ®3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 inches wide and 3 feet below surface. <br /> 1 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 trw_I2CL/LLCOX 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: ( I /r `/" /Z0 � <br /> Grout Inspection By/Date . <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name ALAFAAddress _�9� •'� -�- C,?hffQ FA# 1601 ,51- Z I PIt# 1 0 PiTIA ) <br /> FA PE —�' WP Reviewed By1164 <br /> Work Plan Dale D • 'Lo23 ! <br /> OG57 G57Auff*inWnb(Otherto Sign Permit Oftkers Camp ❑Workee$CWP,WaNer ncroachment Permh ❑Access Agmement Lead AgeeyAppmal MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE SC FEE INFO JAMT R MITTEOJ CHECK# I RECV'D BY I PATE WELL PERMIT# INVOICE# <br /> Permit �� a_ : I [ 2 C - AI 9 u WN If 256 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 ,T�www sjceend.com <br /> END 29-0104-20-23 0 / Site Midgacon Well Permit Application <br /> L. (J <br />