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SAN JOAQUIN 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 fora 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 Mossdale Village citylstate/zip Lathrop, CA Phone (650) 292-9062 Cross Street N/A APN Right-of-Way Property owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive cityistate/zip Lathrop, CA 95330 C-57 Contractor Confluence Technical Services- Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street cityistaterzip Rio Linda, CA 95673 Consultent/sub-contractor EKI Environment & Water License# NA Phone (650) 292-9100 Address 2001 Junioero Serra Blvd Ste 300 Clty/statelzip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsfte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING - ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Naer) 0 HAMMERIDRIVEN DIAL OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) GONDUCTORCASING ❑Yes ❑No Boding Dix Casing Dla: C&Jhg Depth: ❑ INJECTION(NrSoxae.ozo»1 ❑ RAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:MWmum Freefall Depth Is 30 FI) WELL!SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 6 ❑OVER-BORE DIAMETER of_inches to depth offeet WELL IDS MWM-7, MWM-9', MWM-11, MWM-13, MWM-17, MWM-19 OPRESSUREGROUT To depth of2130'feel below surface GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feel below surface R>3 feel COMMENTS: Let, Long (MWM-): 117.80199, -121.3022 (7); 37.80038, -121.2991 (9); 37.80521, -121.3038 (11); 37.80525, -121.2974 (13); 37.80993, -121.3051 (17); 37.81172, -121.2978 (19).The mushroom cap for all wells will be excavated 22 inches wide and 3 feet below surface. 1 hereby certify that 1 am authorized to complete this application and that the work will be done In accordancewith San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed K hWI ditU¢e/:�61ltd¢CCL Title/Company Project Engineer; EKI Environment & Water Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY Application Accepted By: Date Issued: f (—/— f 2- Grout Inspection By/Dates: Destruction Inspection By/Dates: - Facili /Site Information FA Name - i FA Address - 0kW_ FA# I✓ 25 � PRO e— FA PE WP Reviewed By Work Plan Date —e—D ❑C-57 C57AUtWmdonforOtherto Slgn Permk ❑WO(WSCamp ❑Workers Comp Waver gErarlachimlent Permit ❑Atcess Agreement /Lead AgencyApprova MFR COMMENTSI ONS: (T.S !fie-t-Yit� LWs ytlLf rTny -�N''�_ over'T 1 t CO✓f s O >"e fM I J 3� tiout� , s b�1146�e . 1 WP TYPE PE SC FEE INFO JAMT REMITTIED1 CHECK# I REC%rD BY I DATE WELL PERMIT# INVOICE# Permit oz- : &( 12510 1 1 114h#4 O ob Or 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 20 468-34201 IF 209 464-0138 1 wwW.sicA cdr 0EHD 29-01 04-20-23 1-4- 1 Z Z D lot Site Mitigation Well Pe,mil Application