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S A N J O AQ U I N 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 17774 Manlhey Rd. (Let: 37.7985, Long: -121.301) City/State/Zip Lathrop, CA Phone (650) 292-9062 Cross Street Brookhurst Blvd. APN 191-190-33 Property Owner' City of Lathrop Phone (209) 941-7430 Address 396 Towne Centre Drive City/state/zip Lathrop, CA 95330 c-67 contractor Confluence Technical Services, Inc. License# 1035255 "4 > zFgNone 707-639-7709 Address 6821 8th Street cityistate/zip Rio Linda, CA 95673 Consultant/Sub-Contractor EKI Environment &Water License# N/A IPhone (650) 292-9100 Address 2001 Junioero Serra Blvd Ste 300 city/state2lp Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: Note: Offsile Borings/Wells Require Access Agreements or Encroachment Perils TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapxMater) ❑ HAMMERORIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER O SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING OYes ❑No Boded Dia: CWNg Dla: Casing Depth: ❑ INJECTION I&soaae.ozmel ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER O OTHER: GROUT SEAL PUMPED? ❑Yes ONO (Note:Maximum Freefal Depth IS30 Fit WELOSOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_Inches to depth of feet WELL IDs MWM-5 ®PRESSUREGROUT Todepthof 21 feetbebwsudace GROUT SPECIFICATIO _Neva [I EXPLOSIVES From_to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feet below surface if>3 feel COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. _ Signed K {ft2 4L66ittc2G )F�6 19.Q6CfL Title/company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY `/ Application Accepted By: w i�LtF /Date Issued: / 2 —� Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FAName ( V1/ Ni r„« i - FAAddaw -�I%U - 6) vi tw- 'yI� FA# 02 PR# I o fign2o FA PE WP Reviewed By We Plan Dale ❑C57 AulhMzsxm fur Other to Syn Perrin ❑Wodees Camp ❑Wakens Comp WaNa naoachment Peril OAccessAgreem d A ent eagencyAppmVal FR COMMENTSI ONDITJONI WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY I QATE I WELL PER IT# INVOICE# Permit OZ 3 Is oZ 1 C o it Vj V 00 4S 05 a 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.$)cehd.comy, ze EHo 29m1 N-20-23 - I—�I V^ ^, 10 Site Miligalion Well Permit Application-IF V �