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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 Mossdale Village cityistate/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street N/A APN Right-of-Way <br /> Property owner' City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive city/stale/zip Lathrop, CA 95330 <br /> C-67 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street City/state/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: Offate Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vaporlwaler) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boling Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION 0xS w"0, ,el ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum I'melall Depth Is30Fg <br /> WELU SOIL BORING ID; GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 5 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs MWM-1', MWM-2, MWM-3, MVVVl MWM-6 ®PRESSURE GROUT To depth of 21.W,2121 feet below surface <br /> GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to—feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feel below sudace it>3 feet <br /> COMMENTS: <br /> Let, Long (MWM-): 37.79403, -121.3042 (1); 37.79682, -121.3064 (2); 37.79643, -121.303 (3); 37.79808, -121.3027 (4); <br /> 37.80089,-121.3069 (6). The mushroom cap for all wells 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 Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project Engineer: EKI Environment & Water. Inc <br /> Print Name Emmanuel Fonseca Date 26 October 2023 <br /> /DE ART ENT USE ONLY C� <br /> Application Accepted By: G Date Issued: 2 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection Sy/Dates: <br /> Facility/Site Information _ <br /> FAName 6" 4,AjkV1jAwdmnFAAddress 3,q6 FA# PR# p 8 <br /> FA PE �I WP Reviewed By I lWofkPlanDate <br /> 0057 ' 7 Au0Ddzagon for Other to Sign Perml ❑Workers Comp ❑WarkerscompWahmr naoedlmenl Permit ❑AccessAgmananl qkadA9eXyAPproya1 ' FR <br /> COMMENTS/CONDITIONS: -f/ - 5 <br /> P <br /> W TYPE PE SC FEE INFO AMT REMITTED CHECK# RECWD BY I DATE tf WELL PERMIT# INVOICE# <br /> Permit Z W I I L�4 zf o O '15o7--Clo <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 .s�jcAhd cam° <br /> EHD 29-01 04-20-23 I -1 ��-Q 1 0) Site Mitigation Wall Permit Application <br />