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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 18800 Christopher Way (Let: 37.79828 -121.2823) City/state/zip Lathrop, CA 95330 Phone (660) 292-9062 <br /> Cross Street D'Arcy PjW APN 198-130-59 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cityistate/zip Lathrop, CA 96330 <br /> C-67 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street cityistate/zip Rio Linda, CA 95673 <br /> Consultantfsub-contractor EKI Environment & Water License# Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 city/Statelzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX OSTOVE PIPE <br /> ❑ EXTRACTION(Vapxiwaler) ❑ HAMMERMVEN OIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC O OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONWCTORCASING ❑Yes ❑No Bonig Dla: Cesing Dia: Caft Depth: <br /> ❑ INJECTION(Plrsox,0. 1 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE O PIPE <br /> O OTHER ❑ OTHER: GROUTSEAL PUMPED? O Yes O No (Note:Matlmum Freefar Depth Is 30 Fil <br /> WEW SOIL BORING IDs GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs MBRMW-4 ®PRESSURE GROUT Todeplhof 31 feel below surface <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface 0>3 feel <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 inches 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 qJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �{12hZCLittc¢�i �9Atd¢CSCL 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: ti/y ��t ale Issued: I 2 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name j FA Address V0 r I FA# I X e,2,5�9 PR# 0 o <br /> FA PE WP Reviewed By A Work Wan Date a '7 <br /> 0C-61 AC-57Aulhorirz0onfurOtIwlo Sign Permit ❑wakets Comp ❑workers Comp Waver Eipoxhment Permit ❑Ao Agieemenl eae AgemyAppmal - FR <br /> COMMENTS CONDITIONS: - <br /> WP TYPE I PE I SC FEE INFO JAMT RqMITTEDI CHECK# I RECV'D BY OAT WELL PERMIT# INVOICE# <br /> Permit 12A2 13131$10- Y Gkl I 10ZDA W 1 56) S <br /> �o� ?C <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 .s1Ceh .com <br /> EHD2 0104-20-23 ("j_I Tfio to <br /> / Site Mitigation Well Permit Apprration <br />