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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 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 15340 McKinley Ave (Lat 37.82008 -121 2716) citylstaterzip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street Park St APN 198-060-16 <br /> Property Owner" City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cityrstate/zip Lathrop, CA 95330 <br /> C-57 Contractor Confluence Technical Services Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street cityrstaterzip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor EKI Environment & Water License# NA Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 Cityristatelzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsile BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> O EXTRACTION(Vapor/Water) ❑ HAMMERrDRIVEN DIAOFBOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boding Dial: Casing Dla: Casing Depth: <br /> ❑ INJECTION rAYSnvaa Dzmel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes O No (Note:Matdmum Freefal Depth Is 30 FQ <br /> WELUSOIL BORING IDs GROUTSPECIFIGATKNIS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_Inches to depth of_feel <br /> WELL IDs RM W4 ❑PRESSURE GROUT To depth of 31 feet below surface <br /> GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED O AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 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 �la2Ja2Cuuzat �prt2¢CCL 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: T - Yr✓tin Date Issued: �) —( ( -Z 0 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information n I <br /> FA Name ke. r /t't r� FA Address Q A_12_ i9 FA# gZ PR# p �' <br /> FA PE zq L,6 WP Reviewed By Worst Plan Dale Z(� <br /> 111057 fiKC,57Au0horRa1knfwOtherIoSNnPMIt ❑Workers Comp ❑Workers Comp Waiver nnoachmenlPermg ❑Aoce5s Agreement Lead AgemyApproval QI.MFR <br /> COMMENTS/CONDITIONS: <br /> I <br /> I <br /> WP TYPE PE I SC I FEE INFO AMT REMITTED CHECK# I RECV'D BY PATE, WELL PERMIT# INVOICE# <br /> Permit Z O �'I S 16L: n I `p�. I I r' ZL'� <br /> ` 0 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 � T 209 46�Cyy��pp+-3420 i F 209 464-0138 1 'sjcehr�com 2 <br /> EHD 29­01 N-20-23 <br /> 1 � I 0 <br /> O Site MiugaEon Well Permit Appliaoon <br />