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SAN 10AQUIN 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 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 D'Arcy PkwV citylstatelzip Lathrop CA Phone (650) 292-9062 Cross Street Christopher Way APN 198-130-55 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# 1035255 Phone 707-639-7709 Address 6821 8th Street cityistate/zip Rio Linda, CA 95673 Consultant/Sub-Contractor EKI Environment &Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 City/Statelzip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS ❑ MONITOmNG ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VOW/Water) ❑ HAMMERA)MVEN DM.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE O MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL OPVC O OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ONo Boxing Die: Casing Die: Casing Depth: ❑ INJECTION imsmae.OZone1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is30TO WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETERof 10 inchestodepthof 27_8 feel WELL IDS KMW-6 []PRESSURE GROUT To depth of—feet below surface GROUTSPECIFICATIONS Neat Cement [I EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet belay surface or feel below surface if>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. Coordinates (Lat, Long): (37.80076, -121 .2799) 1 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 gther applicable California laws. Signed ( l7LhLCLiLCt2� �BILd2CCL Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY > � Application Accepted By: Lvl C_--_�Date Issued: 2 Q Grout Inspection By/Dates: rl Destruction Inspection By/Dates: Facility/Site Information FA Name t ,I{'t i A FA Address FA# Cr7 J�3 PR# 0 5 * 11 g FA PE ,7 tc WP Reviewed By L Wak Plan Dale (C + �O e ❑G57 C-57 AMigtizatbn for Otherto Sign Pwh OWonkels Camp OWarmers Comp Walver ❑En�croachmenti' mh OAcross Agreement ❑Lead AgencyApproval ❑MFR COMMENTSIC NDITIONS: WP TYPE I PE I SC I FEE INFO JAMT REMITTED1 CH/ECCK# RECV'D BY D pWELL PERMIT# INVOICE# permit Z $I LLK l L/ ' L I I 4 sD 1868 E. Hazelton Avenue Stockton, California 95205 209 468-3420 1 F 209 464-0138 1 www.sicehd.com EHD29-0104-20.23 t -y 1 �� 1 0b Site Mitigation Well Permit Apptiation