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SAN JOAQUIN Environmental Health Department <br /> C- OUNTY— <br /> �,1�1r�wa1 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 Richardson Rd. (Let: 37.81939. Long: -121,3173) City/Statel2lp Lathrop, CA Phone (650) 292-9062 <br /> Cross Street Sutter Rd APN 192-030-51 <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 caylstatelzlp Rio Linda, CA 95673 <br /> Consultant/sub-contractor EKI Environment& Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/state/zip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: OBsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX OSTOVE PIPE <br /> O EXTRACTION(Vapafwater) ❑ HAMMERJDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: O STEEL O PVC O OTHER <br /> ❑ SOILSORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes ❑No Boring Die: Casing Die: Casing Depth: <br /> ❑ INJECTION WGwae.0u 1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED; ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER O OTHER: GROUT SEAL PUMPED? ❑Yes ONo (Note:MaximumFreerall Depth is30TO <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rCHECKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETERof 8 inchestodepthof 19.5 feet <br /> WELLIDS CLSP-3 OPRESSUREGROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS Neat Cement 0EXPLOSIVES From_to—feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS 0 HOSE ®PIPE MUSHROOM CAP 103 feet below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> The mushroom cap will be excavated 20 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 Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ��nJxaatcc¢��eAtaac 2 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: VAfi Date Issued: // Za) 3 <br /> Grout Inspection By/Dates: <br /> DesWction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name 177up TiWA,,jtjvAFAAddress ,-3zb Ce FA# Op Z3 V Z PR# p a <br /> FA PE -7 WP Reviewed By I (A I- Work Plan Daten clv4 <br /> 0G57 C57Au01odzadonfor011wtoSgni' mlt ❑WorkeesG=p ❑warkaesCompWahw EnaoachowtPama ❑Access Agreement LeadAgemyApgoval MFR <br /> COMMENTSIC 0. <br /> ONDITIONS: <br /> WP TYPE PE I SC FEE INFO JAMT REMITTED CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit RoZ 13 $� it [ I t,J n alwl. \AJ Po -os fi <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 15w vv sj�e tl Gom <br /> EHD2M1 D420-23 ^ ,,` I O L Site Mitigation Well Pem*ApphwUon <br />