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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness 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 D'Arcy PkArV cityistate/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street Christopher Way APN 198-130-57 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive citylstate/zip Lathrop, CA 95330 <br /> c-57 Contractor Confluence Technical Services, Inc. License# 1035256 Phone 707-639-7709 <br /> Address 6821 8th Street city/statelzip Rio Linda, CA 95673 <br /> Consultant/sub-contractor EKI Environment & Water License# Phone (650) 292-9100 <br /> Address 2001 Junioero Serra Blvd Ste 300 city/statelzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Opiate BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX D STOVE PIPE <br /> ❑ EXTRACTION(Vap Mateo) ❑ HAMMERORIVEN DVL OF BOREHOLE ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> D SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING D Yes ❑No Bo ing Dia: Casing Dia: CmkV Depth: <br /> ❑ INJECTION rNrSww.0eme1 ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: GAUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER D OTHER: GROUTSEAL PUMPED? ❑Yes ONo (Note:Matdmum Freefel Depth is 30 Ft) <br /> WELL/SOILSORING IDs GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDS KMW-4 QPRESSUREGROUT Todepthof 28.6 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feel below surface 9>3 feet <br /> COMMENTS:Coordinates Lat, Long <br /> ):g): (37.79879, -121.2806). The mushroom cap will be excavated 22 inches <br /> wide and 3 feet below surface. <br /> I hereby certify that I am authorized to complete this application and that the work wl11 be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �l4tVit �Br6aPCCL Title/Company_Project Engineer; EKI Environment & Water. Inc. <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> DEPARTMENT USE ONLY Application Accepted By: Date Issued: 2— <br /> O <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> FacIIItV1SItG Information <br /> FA Name (, G4 - FA Address G FA#'PA �i,>�7� PR# - <br /> FA PE 6 WP Reviewed By Work Plan Date L C) <br /> 0C-57 - C57AutWzatlon for0darto Sign Permit ❑Workers Camp ❑Workers Gang Waver , Encroachment PSOft ❑AxessA9reemenl Lead A9eMyApproval MFR <br /> COMMENTS/ DITIONS: <br /> WP TYPE PE I SC FEE INFO AMT REMITTED1 CHECK# I RECV��'D IIBY DATE '' ,, (WELL PERMIT# INVOICE# <br /> Permit ` $ c I CC' W I) Gie W ooµ'b­C) <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 68-3420 i F 209 464-01381rw w.sJ ehd.com <br /> EHD 29-0104-20.23 I } I •7. .'1. ( D Site Mi69alion Well Permit Applimbon <br />