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SAN JOAQUIN Environmental Health Department <br /> COU NTY— <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 17400 Golden Spike Trail City/statelzlp Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross street Towne Centre Dr. APN 191-350-04 <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# 1035256 Phone 707-639-7709 <br /> Address 6821 8th Street cityistate¢ip 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: Ofrsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORINGDEPTH ❑BOLTED TRAFFIC BOX OSTOVE PIPE <br /> ❑ EXTRACTION(Vap 1water) O HAMMERNRIVEN DWOFBOREHOLE ❑MULTIPLE CASINGS MUL7REVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASINGTHICKNESS TYPE OF CASING: OSTEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING O Yes O No Bair@ Ola: Casing Ora: Casing Depth: <br /> ❑ INJECTION(AYSoaraaoz O HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE OPIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPOMPED7 ❑Yes ONO (Note:MUlmum Fm8WI D"IS30 Fr) <br /> WELUSOILBORINGIDS 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 offeet <br /> WELL IDS MWM-27 OPRESSUREGROUT Todeplhof 24 feet below surface <br /> GROUT SPECIFICATIONS Neal Cement [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ® PIPE ®MUSHROOM CAP ®3feet belowsudace or feet belowsudace if>3 feet <br /> COMMENTS: Coordinates (Lat, Long): (37.8047, -121 .3107). The mushroom cap will be excavated <br /> 22 inches wide and 3 feet below surface. <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done in accordancewith <br /> i+ San JoaquinCounty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 1pr_51M4"/L 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: ,1,. �,� Date Issued: t ,/Tt 2- 0 [ <br /> Grout Inspection By/Dates: <br /> 1J <br /> Destruction Inspection By/Dates: <br /> Facul ISIte Information <br /> FA Name W MVJ FAAddress �C(O FA# O0 'Z3 ,5 PR# 0 1 88 <br /> FA PE WP Reviewed By Work Plan Date 10a Z.OZ.. <br /> 0057 C57AoIWzatbnmrOIlwr(oSignPermh ❑Waders Camp OWadersCanpWaKw EmoachmantPemlh OAc Agmement eadAgencyApprowI MFR <br /> COMMENTS/C ND IONS: <br /> WP TYPE PE I <br /> 2SC�� yy FEE INFO AMT REMITTED CHECK# RECV'D BY AT ' WELL <br /> 1 PERMIT# INVOICE <br /> # <br /> Permit Mo Z, J U t �� r C II Q (V P00g1 5 <br /> 1868 E. Hazelton Avenue I Stockton, Califor�ryla 952D6 I T 209 468-34201 F 209 464-0138 1 w�ww.w.sicehd.com <br /> EHD 29-0104-20-23 1.y)T� 104 Site Mitigation Well Permit Appri bon <br />