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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 This,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job address Mossdale Village city/state/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 city/state/zip Lathrop, CA 95330 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street city/state/zip Rio Linda, CA 95673 ConsultanUSub-Contractor EKI Environment & Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 City/State/Zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringshVells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING - ❑ HOLLOW STEM 80RING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(vow/Yaler) ❑ HAMMERATRIVEN CIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONOUCTORCASING ❑Yes ❑No Bering W: Casing Ole: Casing Depth: ❑ INJECTION fa,se.,,.0rnnol O HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑'OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Madmeen Freelall Depth is 30 Ft) WE W SOILBORING IDs GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 6 ❑OVER-BORE DIAMETER of inches to depth of feel WELL IDs MWM-7, MWM-9•, MWM-11. MWM-13, MWM-17 MWM-19 ®PRESSUREGROUT To depth of2130"feet below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feel below surface or feet below surface if>3 feet COMMENTS: Let, Long (MWM-): 37.80199, -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. I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San�J/oaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed K' 4k W 44.1L¢�i Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY / , , Application Accepted By: h Date Issued: I r/ /T, Gr'� / fl j� Grout Inspection By/Dates: Destruction Inspection By/Dates:_'Fit Facili /Site Information FA Name At i FAAddress i - p>tJAP� I FA# '1 Z� PR/ i— FA PE WP Reviewed By Work Plan Dale (;A- 0 C-57 G57A9Bnd2atbn for Other toSlgn Patent ❑ybrkers Camp ❑Workers Cemp Wavier gEnuoadenentPerenit ❑Aaess AgisherstiQ Lead AgencyApprova MFR COMMENTS) ONS: v , f{,;s t�ernt;� Ca✓ei-s S ou✓S � ��aylua�'• A-Ay -�-,tY� Dyer IWPTYPEI PE I SC I FEE INFO JAMT REMITTED CHECK# I REc%rD BY DATE WELL PERMIT# INVOICE # Permit pZ - L J Ic b 0 -ob- 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 www`.SSll A�.com C) EH029-01W-20-23 j�- ( 2D to (, Site Mitigation Well Permit Application T