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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'Arcv Pkwy city/statemp Lathrop, CA Phone (650) 292-9062 <br /> Cross street Christopher Way APN 198-130-57 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive citylstateizip Lathrop, CA 95330 <br /> c-57 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street cityistate/zip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor EKI Environment & Water License# Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/State/zip Daly City. CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: OHsite Borings/Wells 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 /> ❑ EXTRACTION(VaW/Woteri ❑ HAMMERIDRIVEN CIA OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE 1 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Die: Casing Depth: <br /> ❑ INJECTION(Araoaroe.0,,) ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freald Depth is 30 FQ <br /> WELUSOIL BORING IDS GROUT SPECIFICATIONS <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_feet <br /> WELL[Os KIAW-4 10PRESSUREGROUT Todepthof 28.6 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feel below surface R>3 feet <br /> COMMENTS:Coordinates Lat, Long <br /> ):g): (37.79879, -121 .2806). The mushroom cap will be excavated 22 inches <br /> 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 qJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Tine/company Project Engineer EKI Environment & Water Inc <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> DEPARTMENT USE ONLY / 0 �� <br /> Application Accepted By: Date Issued: l <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information IL <br /> FA Name � FA Address (Cl Oil FA# pR# <br /> FA PE 6 WP Reviewed By _ �' Work Plan Date CZ.� <br /> ❑C-57 CS7ANIlodzatlon forONerNSpn Permit ❑Workers Cornp ❑Workeescompwalver , Erxxoad2tPermO ❑Act�aseAgreemenl Lead AgemyApproval MFR <br /> COMMENTSIC DITIONS: <br /> JWPTYPEJ PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit r x j CG �J i ) 6 kelUJ 004 S6 <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 68-3420 i F 209 464-0138 1 www.sicehd.com <br /> EHD 29-0104-20-23 1 S- I •-/. -y ( O b Site Mitigation Well PennitApplineon <br />