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SAN 10AQUIN Environmental Health Department <br /> —COUNTY— <br /> Greotness 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 city/state/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street WA APN Right-of-Way <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive cityistatelzip 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/State0p 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 ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporWaler) ❑ HAMMERNWVEN DA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OR <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILSORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes []No Boling Dia: Casng Dia: Casing Depth: <br /> ❑ INJECTION WSD,,e. zml ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Matlmum Freefall Depth is 30 Ft) <br /> WELUSOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 5 ®OVER-BORE DIAMETERof B_inches to depth of 20=feel <br /> WELL IDs MWM-20, MWM-21, MWM-22',MWM-23,MWM-25 ®PRESSURE GROUT To depth of 21 feetbelowsurfam <br /> GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP o 3 feet below surface or feet below surface d>3 feet <br /> COMMENTS: <br /> Let, Long (MWM-): 37.81184, -121.3097 (20); 37.81367, -121.3036 (21); 37.81257, -121.3152 (22); 37.8165, -121.306 (23); <br /> 37.81849, -121.3109 (25). The mushroom cap will be excavated 22 (20*) inches wide and 3 feet below surface. <br /> I hereby certify that I am authorized to complete this application and thatthe work will be done in accordance with <br /> San qJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �hf{�ZCUtG[¢G �9�td2CSCL 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: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name /{') FAAddress `� pp✓A.�. FA# 0 r � PEW Q : [ <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-51 PtZZAuUhorizatiunforOdlerk Sgn Peanb ❑Workers Camp pWarkersCompwahw ocroachmenl Permg ❑AccessAgreemenl AgencyApprowJ QJER <br /> COMMENTSICONDITIONS: // _ (� <br /> lam. uN1( c Crjv2Vs °u+"� c� 6 f_Q_r`L0' fi11f�2 . <br /> WP TYPE PE I SC FEE INFO AMT REMITTED1 CHECK# I RECV'D BY DtTg WELL PERMIT# INVOICE# <br /> Permit Zjj>13 J%Lx 910 1 C, C`__ ( ' zirz WFOO 5v6 y� <br /> - '�ct{— U <br /> 1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 $Ic d-c1 ehd._oom <br /> EHD 29-01 0420-23 1 ` -�' O Site Mitigation Well Permit Application <br />