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SAN JOAQUIN Environmental Health Department COUNTY— .... ..... Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. _ This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address Richardson Rd. (Let: 37,81939, Long: -121.3173) City/State/Zip Lathrop, CA Phone (650) 292-9062 Cross Street Cutter Rd APN 192-030-51 Property Owner* City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive City/State/Zip Lathrop, CA 95330 C-67 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street cityistate/zip Rio Linda, CA 95673 Consultant/sub-contractor EKI Environment & Water License# N/A Phone (650) 292-9100 Address 2001 JuniOero Serra Blvd Ste 300 CitylState/Zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: `Note: ORsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERNRIVEN Dlk OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIN ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING O PUSH POINT(GP/CPT) CONDUCTORCASING OYes ONO Bodrq Dla: Casing Die: Casing Depth: ❑ INJECTION WSwae.Omnel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HWE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes O No Mote:Maxknam Freefall Depth Is 30 FQ WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETER of 8 inches to depth of 19.5 feel WELL IDs CLSP-3 ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface#>3 feel COMMENTS: The mushroom cap will be excavated 20 inches wide and 3 feet below surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �YAthAQGAtGZ2� 619.Zt lSCL Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY > Application Accepted By: M ! Date Issued: Grout Inspection By/Dates: ._ Destruction Inspection By/Dates: �— FacilltvISite Information FA Name (2ry �,� , : ' ITj FAAddress 3b o0U--Co PR# 0,54HRO FA PE a— WP Reviewed By "-' - Work Plan Date 0057 C57 AWpdiallonfor Other to Sign Pemilt OWorkefs Comp OWarkerSCOmpWalver EncroaMnentPermil OAo=Agreement t lead AgeWyApprOM MFR COMMENTSICONDITIONS: WP TYPE PE I SC FEE INFO AMT REMITTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit gpZ- 3l3s( Z( 1IC,L IsfAd II 9/2u PD 'o5� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 swwww sicehd.cor ZO EHO 29-01N-20-23 Ifi I —j—c) ID / Site MiGOetlon Well Permit Apgimbon'