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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> `�+/,,,�1,a�` Greotness 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 17774 Manthey Rd. (Let: 37.7985, Long: -121.301) City/state/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street Brookhurst Blvd. APN 191-190-33 <br /> Property Owner* 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# 1035255 tKP 2F one 707-639-7709 <br /> Address 6821 8th Street city/state/zip Rio Linda, CA 95673 <br /> ConsultantfSub-contractor EKI Environment & Water License# N/A IPhone (650) 292-9100 <br /> Address 2001 Junioero 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 OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING 0 HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX 0STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) O HAMMERAWVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0STEEL ❑PVC 0 OTHER <br /> ❑ SOILBORING 0 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ONO BWPg Dla: Casing Oa: Casing Depth: <br /> ❑ INJECTION m soerae.oimel 0 HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS OHOSE 0PIPE <br /> ❑ OTHER 0 OTHER: GROUTSEAL PUMPED? Oft ONO (Note:Maimum freelall Depth is 30 FQ <br /> WELU SOILBORING IDs GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) <br /> If WELLS TO BE DESTROYED 1 [1 OVER-BORE DIAMETER of_inches to depth of_feel <br /> WELL IDS MWM-5 ®PRESSUREGROUT Todepthof 21 feet below surface <br /> GROUT SPECIFICATIO _ Neon ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM GAP 03 feet below surface or feet below surface 9>3 feet <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 inches wide and 3 feet below surface. <br /> I 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: /(r��.T,J— Iti CLW-1 Date Issued: L l / I I <br /> -- <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faclli /Site Information <br /> FA Name U FA Ad� - I,1/A.Q_ 6401 FA# I QC> Z,3L PR# 1 0 g� <br /> FA PE WP Reviewed By Work Plan Date <br /> 0057 7AWMrizatlonfaOWertoSynPams ❑Workers Comp, OWakersCompWaNW ncroachmenlPermit ❑A=wAgreenieni eWAgercyApprova FR <br /> COMMENTS) ON DITIONS: <br /> jWPTYPEj PE I SC I FEE INFO <br /> AMT REMI <br /> TTED CHECK# I RECV'D BY I PATE I WELL PE IT# INVOICE# <br /> Permit Z o2 S13 Is cL vj II w A Vj V00 05 <br /> J"b if2e <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 2/p09 468-3420 1 F 209 464-0138 1 viww.sjcehd.com <br /> EHD 29-0104-20.23 I�I �1 q-o ID V Site Mifigation Well Permit App+inGon <br />