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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 D'Arcy Pkwy - city/staterzip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street Christopher Way APN 198-130-54 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive ch y/state/zip Lathrop, CA 95330 <br /> C-By contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street city/staterzip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor EKI Environment &Water License# NA Phone (650) 292-9100 <br /> Address 2001 Juniper0 Serra Blvd Ste 300 city/stalerzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapahYaer) ❑ HAMMERIDRIVEN DM.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ONO BOag Dia: Casing Dia: C"Depth: <br /> ❑ INJECTION(&So .Deme1 ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPETOB UUSED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Mulmum Freefal Depth 1530 Ft) <br /> WELD SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETERof_inches to depth of_feet <br /> WELL IDS KMW-8 ®PRESSURE GROUT To depth of 31 feet below sudace <br /> GROUT SPECIFICATIONS Neal Cement [I EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP IA 3 feet below surface or feel belowsurface'rf>3 feet <br /> COMMENTS:Coordinates (Lat, Long): (37.80041 , -121 .2837). The mushroom cap will be excavated 22 inches <br /> wide and 3 feet below surface. <br /> 1 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_(- tM49 94a- bssaalSCG 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: w Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspec0on By/Dates: <br /> FacilithilSite Information 7� <br /> FA Name t M, �u FA Address trf - FA# I C)Q'[;3 cj c. I PR# —I' <br /> FA PE WP Reviewed By Work Plan Date Z023 <br /> ❑C57 7 AualednIODn for Oderio Sign Pemtll ❑Wakens Cane ❑WakenSCamp Walla Encroachment PWet ❑Ac Agmement - Lead Agency Approval FR <br /> COMMENTSI ONDITIONS: <br /> JWPTYPEJ PE I SC I FEE INFO AMT REMITTED1 CHECK# I RECV'D BY DATE, WELL PERMIT# INVOICE# <br /> Permit Z $ ti I din Il R 4v Poo45o63 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 20pr 468-3420 1 F 209 464-0138 1 SwfW-0WLSlcrAd com <br /> EHD N-01 U-20-M I —v 1 T^ p1 0 <br /> _/ Site Mitigation well Pemn Apgmanon <br />