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SAN 10AQUIN Environmental Health Department --COUNTY— Greotness 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 740 Green Pz (Lat 37.78452 Long: -121.3387) city/state/zip Lathrop, CA 95330 Phone (650) 292-9062 Cross street Village Ave APN 191-380-67 Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive cityistate/zip Lathrop, CA 95330 c-57 contractor Confluence Technical Services, Inc. License# 1036255 Phone 707-639-7709 Address 6821 8th Street Oitylstate/zip Rio Linda, CA 95673 Consultanusub-contractor EKI Environment & Water License# N/A Phone (650) 292-9100 Address 2001 Junioero Serra Blvd Ste 300 City/Statelzip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsWells Require Access Agreements or Encroachment Perils TYPE OF WELU13ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporNate) ❑ HAMMEPoDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTH.EVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Bodng Dla: Casing Dla: Casing Depth: ❑ INJECTION Maoaae.Dzant ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is 30 Ft) WEW SOIL BORING IDS GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THATAPPLY) #WELLS TO BE DESTROYED 1 El OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs MWM-15 ®PRESSURE GROUT Todeplhof 21 feet below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. 1 hereby certify that 1 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 K Title/company Project Engineer; EKI Environment &Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 -DEPARTMENT USE ONLY 11 Application Accepted By: 4 IA / Dale Issued: Z 3 Grout Inspection By/Dates: 1 Destruction Inspection BylDales: Facill ISile Information FA Name C2f l /Vl yyl FAAddress . iQ j/g,.jAA- :�-�'�Q_ FA# b� +j$'� PR# 6 Igo FA PE WP Reviewed By Work Plan Date I C 2 ❑C-57 7AuI1Mza5onfcrOI1*rlo Spn Permit ❑Workers Camp ❑Workers Comp WaNer lidEncroachmentPerm ❑Access Agreement AgenApprowJ MFR COMMENTSICONDITIONS: WP TYPE �!PE ) SC FEE INFO AMT REMITTED CHHECK# RECV ID, 3Y D T WELL PERMIT# INVOICE# Permit !-(01- Ek ZX I (-C- V\ I li) LZ I VJ1p(vg5o51+ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 I www.s ce ld.com EHD 20-01 M-20-23 ( � I,�`,�—(.� ID� Site MiugaEon Well Permit( / i l AppliceEon