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0. <br /> SA N . J 0AQ U I N Environmental Health Department <br /> ,P COUNTY — <br /> °�� '' Greatness gre)vs 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 444 Mossdale Road City/State/Zip Lathrop, CA 95330 Phone <br /> Cross street N/A APN 239-030-03 <br /> Property Owner' SKSP Inc. Phone 510-364-5771 <br /> Address 1172 C Street City/State/Zip Hayward, CA 94541 <br /> C-57 Contractor Environmental Control Associates (ECA) License# 695970 Phone 831-662-8178 <br /> Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 <br /> Consultant/Sub-contractor Partner Engineering & Science, Inc. License# Phone 774-414-3666 <br /> Address 490 43rd Street City/State/zip Oakland, CA 94609 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" [:]MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 5 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BCRING IDs 61 through B5 GROUT SPECIFICATIONS Borings WIII be grouted Wlth/neat cement via tremmie <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑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 if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed / ''e Title/Company Project Manager/Partner <br /> Print Name Michel Helou Date 5/28/2026 <br /> I DEPARTMENT USE ONLY j <br /> Application Accepted By: Date Issued: <br /> L <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name _ FA Address FA# PR# <br /> FA PE _ WP Reviewed By Work Plan Date r <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp aiver— Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: C'0 <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit j '$179 x 7' 2221501218 21543122 4' .� �/� L W Pl6�/ 1`tY <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 Site Mitigation Well Permit Application <br />