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SAN JOAQUIN Environmental Health Department COUNTY— "q„F1,,,,1'V;" 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 for a 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 18800 Christopher Way city/state/zip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Testa Or. APN 198-130-35 Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive City/stateizip Lathrop, CA 95330 C-57 contractor Confluence Technical Services, Inc. License# 1036256 Phone 707-639-7709 Address 6821 8th Street cuyristate/zfp Rio Linda, CA 95673 ConsultantiSub-contractor EKI Environment& Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 CIWState2lp Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapuNater) ❑ HAMMERNWVEN DMA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dla: Cwingaa: Casing Depth: ❑ INJECTION Us seams Ozmel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Ma imam Frelfal Depth Is 30 FQ WELU SOIL BORING IDS - GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 La OVER-BORE DIAMETERof 10" inchesto depth of21" feet WELL IDS MBRMW-1, MBRMW-2', MBRMW-3" Ia PRESSUREGROUT Todeplhof2a,ze• (eetbelowsurface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE O PIPE ®MUSHROOM CAP ®3 feel below surface or feel below surface If>3 feet COMMENTS: Coordinates(Let, Long): (37.79569, -121.2853), (37.79486, -121.2848)', (37.79522, -121.2869)". The mushroom cap for all three wells Will be excavated 22 inches wide and 3 feet below surface. 1 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 �hZhLCuuz¢e�9Ata¢!�t Title/Company Project Engineer; EKI Environment & Water, Inc. print Name Emmanuel Fonseca Date 26 October 2023 1 PARTMENT USE ONLY / r7 Application Accepted By: Date Issued: Grout Inspection By/Dates: iz Destruction Inspection By/Dates: L Fa III /Site Information FA Name M / FAAddress PR# O f4lH I 0 FA PE WP Reviewed By I Work Plan Date L 0 C-57 7AWtorizatlon for OtherloSlgn PeOnll ❑Workers Comp ❑WorkefsComp Waiver ExroechmenlPelmh ❑Aces Agreement AgemYApprowdl COM M E NTSICO N DITIONS: JWPTYPEJ PE I SC I FEE INFO JAMT REMITTADI CHECK# I RECV'D BY I DtIll WELL PERMIT# INVOICE# Permit I Z D 30 3 s _3 ' I I Zr. o o -p ��Z 1868 E. Hazelton Avenue Stockton, California 95206 ( T 209 46 -3420 1 F 209 464-0138 .s�d-com EHD 20-010420-23 1 T 1 '- �Ln 10 6) Site Mitigation Well Permit Application