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SAN JOAQUIN 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 fora 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 Mossdale Village cityistatefzip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street N/A APN Right-Of-Way <br /> Property owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cityfstate/zip Lathrop, CA 95330 <br /> c-67 contractor Confluence Technical Services, Inc License# 1035265 Phone 707-639-7709 <br /> Address 6821 8th Street city/state/zip Rio Linda, CA 95673 <br /> ConsultanUSub-contractor EKI Environment &Water License# Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 citylStatefzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaWMalef) O HAMMERowEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORGASING ❑Yes ONO Bodlp7Dia: Casirg Dle: Casing Depth: <br /> ❑ INJECTION wSmrm.omrel O HANDAWER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER O OTHER: GROUTSEAL PUMPED? ❑Yes ONO (Note:Mapmum FmIall Depm is 30 FQ <br /> WELU SOIL BORING IDs GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED 5 ®OVER-BORE DIAMETER of B' inches to depth of 20_feet <br /> WELL IDs MWM-20, MWM-21, MWM-22*, MWM-23,MWM-25 ®PRESSURE GROUT To depth of2?feet below surface <br /> GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑-HOSE®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface B>3 feet <br /> COMMENTS: <br /> Lat, Long (MWM-): 37.81184, -121.3097 (20); 37.81367, -121.3036 (21); 37.81257, -121.3152 (22); 37.8165, -121.306 (23); <br /> 37.81849, -121.3109 (25). The mushroom cap will be excavated 22 (20') inches wide and 3 feet below surface. <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San�J/oaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �hZyiLCLIZLC¢(i �6/yG.Q.CSCL 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: Date Issued: <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dales: Ase;A / Z— (2 2— <br /> Facili /Site Information <br /> FA Name ry) FAAddress pWAQ_ FA# PR# Q — L <br /> FA PE WP Reviewed By Wolk Plan Dale �' <br /> ❑C57 Pt57­AuWzathnfxOftrto Sqn Pernik Ow~sComp ❑wMelsoompwaim ncroachment Pemlg ❑Access Agreement AgencyApprowal R <br /> COMMENTS/CONDITIONS: , /� <br /> � t 5 rrl iv - (6v)e -S 5, Dory a� 6 _ I CL <br /> IWPTYPEI PE I SC FEE INFO JAMT REMITTED1 K# I RECV'D BY D#%Tq WELL PERMIT# INVOICE# <br /> 0 $.. <br /> Permit X 2; 10 1 CC I - (141zfz 00 506 V <br /> cl -1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 ' .$)cehd�om <br /> EHD 29-01 04-20-23 --I D Site Mi gaEon Wee Permit Appliweon <br />