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SAN JOAQUIN Environmental Health Department COUNTY 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 fora permit to construct and/or install the work described. This application is made m compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin Counly Well Standards. Job Address 18800 Christopher Wav cityistatiI Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Tesla Dr, APN 198-130-35 Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive citylstate/zip Lathrop, CA 95330 C-57 contractor Confluence Technical Services, Inc. License# 1036266 Phone 707-639-7709 Address 6821 8th Street city/staterzip Rio Linda, CA 95673 Consultant/Sub-contractor EKI Environment & Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 City/state/Zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: `Note: Ogsile Borings/Wells 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(VaWAWaer) ❑ HAMMER,DRWEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boling Me: Casing Dla: Casing Depth: ❑ INJECTION LAWSoao ,Cei l ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth IS30 FQ WEW SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER-BORE DIAMETER of 10'• Inches to depth of 21" feet WELL IDS MBRMW-1, MBRMW-2•, MBRMW-3" OPRESSUREGROUT Todepthof24,26' feet below surface GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface g>3 feet COMMENTS: Coordinates(Let, Long): (37.79569, -121.2853), (37.79486, -121.2848)•, (37.79522, -121.2869)". The mushroom cap for all three wells will be excavated 22 inches wide and 3 feet below surface. I hereby certify that 1 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 �lxJxa�tuoe�eitaPcs2 Title/Company Project Engineer; EKI Environment & Water Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY Application Accepted By: 1A Date Issued: Grout Inspection By/Dates: JZ Destruction Inspection By/Dates: Faclli /Site Information FAName / -FAAddress D / L. FA# p 6 PR# 0 FA PE ZC"1 WP Reviewed By Work Plan Dale _L ❑C-57 7AWerizatimforOtferro Sago Permil ❑Workers Comp ❑Workers Canp Waiver Encroachment Permit ❑Access Agreemeol serf AgemyAWow# COMMENTS/CON DITIONS: WP TYPE PE I SC I FEE INFO JAMT REMITTED REMITTED1 CHECK# I RECV'D BY I D TE WELL PERMIT# INVOICE# Permit 3 3 tI Ll b0 ,io6rZj 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 46fl-34201 F 209 464-0138 w.sj ee di corm EHD 29.01 0420-23 ` 2 1 -71-0 to b Site Mitigation Well Permit Application