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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> ,, ,w" , 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 18800 Christopher Way (Let: 37.79828, -121.2823) Citylstatelzip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street D'Amy PbW APN 198-130-59 <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 cltylstate/zip Rio Linda, CA 95673 <br /> Consultandsub-contractor EKI Environment & Water License# Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 CIWState2lp Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: O#site BoringslWells Require Access Agreements or Encroachment Permits <br /> I <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM 80RING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapon'Waler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING CIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING El Yes ❑No Bodng Dla: Casing Ole: Caing Daplh: <br /> ❑ INJECTION(Nrsaame.Oz w1 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Mmftn FrWl#I Depth Is 30 Ft) <br /> WELUSOIL BORING IDS GROUTSPECINCATIONS <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 MBRMVV4 OPRESSUREGROUT Todeplhof 31 feel below surface <br /> GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to_feet belay surface <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOSE ®PIPE ®MUSHROOMCAP 03 feet belay surface or feet below surface#>3 feel <br /> COMMENTS: <br /> The mushroom cap will be excavated 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 accordance with <br /> San qJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed !�M41, ItLGe(. �99Q42 Title/company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> EPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name A4jy ZroFA Address 0 "rly, 1,ewk I FA# DQ PPoI (g Qj <br /> FA PE W5 WP Reviewed By Work Plan Dale 2 ' '� <br /> ❑G57 G57AuiWaUonfor0therto Sgn P.ft ❑workers Comp ❑Wonlers Comp Waiver EraoadromtPermit ❑Awoss Agreement 'le e"Agem -yApproval FR <br /> COMMENTS CONDITIONS: <br /> WP TYPE I PE I SC I FEE INFO JAMT RqMITTEDI CHECK# I RECV'D BY I D00,TE I WELL PERMIT# INVOICE# <br /> Permit J 8 K W j� ZD I/�l 5C) S <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I Www.$)ceh .com <br /> EHD29-0104-20-23 ,12I 7Po 10 / site Mlneanon Well Permit Apglcanon <br />