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SAN JOAQUIN Environmental Health Department COUNTY— m�w"' Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 15360 McKinley Ave(Lat: 37.82123 -121. 268) City/Statelzip Lathrop, CA Phone (650) 292-9062 Cross Street Park St. APN 198-060-17 Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive citylstatelzip Lathrop, CA 95330 C-57 Contractor Confluence Technical Services, Inc. License# 1036255 Phone 707-639-7709 Address 6821 8th Street cityistateizip Rio Linda, CA 95673 Consultant/sub-contractor EKI Environment & Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 citylstatelzip Daly CitV, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE . ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes ❑No Boling Dia: - Casing Die: Casing Depth: ❑ INJECTION tw,S,owner ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: - GROUTSEAL PUMPED? ❑Yes ONO (Nola:Maximum Freefall Depth IS30 Fl) WELUSOIL BORING IOs GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALLTFIAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_Inches to depth of_feel WELL IDs RMW-5 ❑PRESSUREGROUT Todepthof 31 feet below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ® PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface it>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �hZhZCUf �B7s¢aCGL Title/Company Protect Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY Application Accepted By: i � Date Issued: Grout Inspection By/Dates: / Destruction Inspection By/dates: Facili /Site Information FA Name M H loth FA Address LO r k- FA# C'C> L4,�9i Z PR# L o FA PE - GJ WP Reviewed By -/ Work Plan Date Z[1'- '> 0C-57 C57Auaerizabonfor0lherlo Sign Permit OWoikees Carp ❑Worrers Comp Waiver Encroachment Permit ❑Access Agreement Agency Approval FR COMMENTS/ NBITIONS: WP TYPE I CPE S'C7 FEE INFO AMT REMITTED CHECK# REC1V'D BY D,7T�n 1/tIWELL PERMIT/#,,, INVOICE# Permit ZqU g!J LX J� t( 'T Gv Y• 0() 5-060 K00 2p 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 11 WWW.6 C com EHD29-01 W-20-23 i ?— l q- :iLV I (l / Site Mitigation Well Permit Application