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1 <br /> SANJOAQUIN 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 Pkwy C[Wstatelzip Lathrop, CA Phone (650) 292-9062 <br /> Cross street Christopher Way APN 198-130-54 <br /> Property Owner' City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cltylstatelzip Lathrop, CA 95330 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street citylstatelzip Rio Linda, CA 95673 <br /> ConsultantfSub-contractor EKI Environment & Water License# NA Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 Citylstate¢ip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsfte BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaWMalef) ❑ HAMMERARVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPICPT) CO,NDUCTORCASING ❑Yes ❑No String Oia: Casing Dla: Casing Depth: <br /> ❑ INJECTION bkkti na0zme) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madmum Freafall Depth is 3D FQ <br /> WELL/SOIL BORING 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 /> WELL IDS KMW-S Ia PRESSURE GROUT Todepthof 31 feel below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP 03 feet below surface or feet below surface 1>3 feet <br /> COMMENTS:Coordinates (Lat, Long): (37.80041 , -121 .2837). 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 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 /> DE ARTMENi USE ONLY / <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: • Z. <br /> Facill /SI a Information <br /> FA Name , uk di1) 1 FAAddress _ �� L FA# PFU Lf- <br /> FA PE WP Reviewed By Work Plan Date I CY ct- ZU` <br /> ❑C-57 7AWIMratlonforOIherto Sqn Permit ❑Workerscolnp ❑workers comp waiver EnaoachmentPennit ❑Access Agreement - Lead AgemyAppeval §hFR <br /> COMMENTS/CONDITIONS: <br /> JIMPTYPEJ PE I SC FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY DATE, WELL PERMIT# INVOICE# <br /> Permit Z '� 19k, r, � jt q zo . Po0450Q <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 20pr 468-34201 F 209 464-0138 1 'www sjce d com <br /> EHO 29-01 W-20-23 1 <br /> --:v I -r �-010 / Site Mltiostion Well Penolt Applicatlon <br />