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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grows hei <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 740 Green Pz (Lat: 37.78452, Long: -121.3387) City/State/Zip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street Village Ave APN 191-380-67 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive city/state/zip Lathrop, CA 95330 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street City/State/Zip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor EKI Environment & Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 city/State/Zip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparne,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING ID5 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 /> WELL IDs MWM-15 ® PRESSURE GROUT To depth of 21 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑ 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: <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_ 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: it ZZO Z <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information llloww�w <br /> FA Nam Irp. �1�, FA Address - FA# �r <br /> e PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $ X v�. I1 4 U,' I tv,f J r✓ J Li <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjceif d.com <br /> EHD 29-01 04-20-23 1_7��I / O/, Site Mitigation Well Permit Application <br />