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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 15360 McKinley Ave (Let: 37.82123, -121. 268) city/state/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross street Park St. APN 198-060-17 <br /> Property Owner' City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive citylstate/zip Lathrop, CA 95330 <br /> c-57 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street citylstate/zip Rio Linda, CA 96673 <br /> ConsultanflSub-Contractor EKI Environment&Water License# NA Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/State/Zlp-Daly City. CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vaponwater) ❑ HAMMERNRNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILSORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boning Die: - Casing Dia: Casing Depth: <br /> ❑ INJECTION MSo ..Oimal ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: - GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefill Depth is 30 Fit <br /> WELUSOILSORING 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 IDS RMW-5 ❑PRESSURE GROUT To depth of 31 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 ®3 feet below surface or feel below surface >3 feet <br /> COMMENTS: <br /> The mushroom cap will be excavated 22 inches 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�Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �t14tCLJZLI¢� 61924C,a, 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: OffDate Issued: Z2...r�— <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA NameFAAddress U R#-j j o <br /> FA PE WP Reviewed By Work Plan Date <br /> 0C-57 C-57 AmllpizaUDn for Other to Sign Permk ❑workers Gomp ❑workers Compw;Jw Enaoaduneni Permit ❑Access Agreement a1AgemyAprowtl FR <br /> COMMENTS/' NOITIONS: <br /> WP TYPE I <br /> pPE S,C77 FEE INFO AMT REMITTED CHECK# RECIV'D BY D�7T '/'WELL PE�RMIT/# INVOICE# <br /> Permit 2q0 9v S. Lk I ' J�VV it '7 &0 1• OU 5-06�0 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 l F 209 464-0138 r1v1 wow�ehd.com <br /> EHD 2MI04-21-23 1 ?- I A lD / Site Mitigation Well Permit Application <br />