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SAN JOAQUIN Environmental Health Department <br /> —COUNTY <br /> '?Ic,,.0w'0. 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 17681 S Howland Rd cityistaterzlp Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street D'Arcy Pkwy APN 19801032 <br /> Property owner' City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive Olty/statelzip Lathrop, CA 95330 <br /> c-57 Contractor Confluence Technical Services, Inc. License# 1035265 Phone 707-639-7709 <br /> Address 6821 8th Street city/state/zip 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: Offske BorngsA/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaPAVaeQ ❑ HAMMERATRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> 0 SOIL VAPOR PROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING El STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boft Die: Casing DM: Cwing Depth: <br /> ❑ INJECTIONIarsoe,ee.D.me) ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TORE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (tfnte:Madman Freefall Depth is 30 FQ <br /> WELLI SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> At WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDs KMNH9 ❑PRESSURE GROUT Todepthof30 feetbelowsurace <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP 03 feet below surface or feel below surface 1>3 feet <br /> COMMENTS:Coordinates Lat, Long <br /> ):g): (37.80081 , -121.2774), On the side of the street. The mushroom cap <br /> will be excavated 20 inches wide and 3 feet below surface. <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 Title/Company Project Engineer EKI Environment & Water Inc. <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> DEPARTMENTUSE ONLY I - <br /> Application Accepted By: Date Issued: I ( ,� /�d Z� <br /> Grout Inspection By/Dates: <br /> t <br /> Destruction Inspection By/Dates: <br /> Facill /Site Information � <br /> FAName LAIAra G MW 0)tf)U FA Address D Ip. a e*f1-(_ I FA# 3 9z PR# 0 5Ltil go <br /> FA PE Zq 6.7 WP Reviewed By ,J Wort Plan Date O C Z 0 L,3 I <br /> ❑C-57 JUP,57 AulindmIlDn low Other IDSlgn Pemu! ❑Workers Camp ❑Workers Comp Walter EncteachmentPermh ❑Access Agreement Leae AgencyAppr MFR <br /> COMMENTS/CONDITIONS: <br /> jVVPTYPEj PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECv'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 29oZ 'Ibl ` I � 69 CC ,�J It 9 lOC FoOL4505 / <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 f"sj ehd com <br /> EHD 2a-o1 04-2 23 (-t` I q-3-0 t 0 L site Mlagaronwell PenretApaeation <br />