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SAN -JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> `1140a.Q'` 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 17100 Golden Valley Pkwy(Let:37.80589,Long:-121.2989) City/state/Zip Lathrop, CA Phone (650) 292-9062 <br /> cross street Towne Centre Dr. APN 191-190-49 <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 /> OonsultanUSub-contractor EKI Environment&Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/Statelzip 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 /> O MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX OSTOVE PIPE <br /> ❑ EXTRACTION(VapoiMatei) O HAMMERA RIVEN 010.OF BOREHOLE O MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC O OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes O No Bodrg OW: Casing Die: Casing Dow <br /> O INJECTION(AhSmee,Ozone] ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: GAUGERS OHOSE OPIPE <br /> ❑ OTHER O OTHER: GROUTSEAL PUMPED? OYes ONo (Nola:Ma)dmum Freefal Depth is 30 Ft) <br /> WELL/SOIL BORING IDS GROUTSPECIFICATIONS <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 MWM-12 0PRESSUREGROUT Todepthof 21 feel below sudace <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED OAUGERSOHOSE ®PIPE 0MUSHROOM CAP 03 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 /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> s Joaquin corn Ordinance codes and Standards, <br /> Titl Title/Company II otProject Engineer;her applicable <br /> a laws. <br /> Signed KI Environment & Water, Inc. <br /> Print Name Emmanuel Fonseca JJJ Date 26 October 2023 <br /> Application Accepted By: at�a,/�F/—� aI n t�/` DEPARTMENT USE ONLY Date Issued: <br /> Grout Inspection By/Dale r U t <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FAName (4YllM ,L FAAddress :3qO A.—Ap— FA# 00 Z35-92 PIN 11,30 <br /> FA PE I I r7c, _ WP Reviewed By Work Plan Date 2� <br /> OC-51 G57Au0oriz8fonforOtherto SIimPMft ❑Wooers Comp OWooers Comp Waiver gEWoXhmantPWM ❑Aa Agreement Lead AgencyAppMal FR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE pPE7 SC I FEE INFO JAMT REMITTED1 CHECK# RECV'D BY ATE WELL PERMIT# INVOICE# <br /> Permit 2,l o C� 3 1 ILL U— -Tu"' I ;I p zC \000 SD52 - <br /> 5rt0liwiF z <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD2"104-20.23 I: / �T —To <br /> 10,6 <br /> Site Mitigabw Well Permit Appricabon <br />