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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 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 D'Arcy Pkwy Citylstatelzip Lathrop, CA Phone (650) 292-9062 Cross Street Christopher Way APN 198-130-55 Property Owner' City of Lathrop Phone (209) 941-7430 Address 390 Towne Centre Drive City/statelzip Lathrop, CA 95330 C-57 Contractor Confluence Technical Services, Inc. License# 1035265 Phone 707-639-7709 Address 6821 8th Street cityistatelzip Rio Linda, CA 95673 ConsultanHsub-Contractor EKI Environment&Water License# NA Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 city/Statelzlp 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 0 HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ E)(TRACTION(Vap /Water) ❑ HAMMER,DRIVEN D0.0F BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING OIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑P/C (] OTHER ❑ SOILBORING O PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Die: Casing Depth: ❑ INJECTION(A &,o.Oiawl ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Macimum Freefall Depth is 30 F1) WELUSOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 96 OVER-BORE DIAMETER of 10 inches to depth of 27.8 feet WELL IDS KMW-6 ❑PRESSUREGROUT Todepthof_feetbebwsudaw GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to feet below sudace TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE IA MUSHROOM CAP 03 feel below surface or feel below,surface if>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. Coordinates (Lat, Long): (37.80076, -121 .2799) 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 yther applicable California laws. Signed K yM4 6d><t Title/company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Data 26 October 2023 DEPARTMENT USE ONLY >> TT Application Accepted By: 4L11Date Issued: I 2 0 C� Grout Inspection By/Dates: Destruction Inspection By/Dates: FacilitylSito Information FA Name FAAddress 1 /r.�Jr1.L- - �t.�� FA# MZ3 3 PR# I cis'*Ilgo FA PE WP Reviewed By Work Plan Date O `e Z C)e__s 0"7 CB7AWiodzeIImforOlherto%nPennh ❑WodcersCanP ❑Workers Comp W*0` ❑Emroachmenl Peneh ❑AowssAgreemenl ❑Lead Agency Approval ❑MFR COMMENTS/ NDITIONS: WPTYPEj PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I D T I WELL PERMIT# INVOICE# Permit ii�o-'2, I 2j s isi w,t iI I tc), cc, I suo I 114 & - W rbo -0 u+ 1868 E. Hazelton Avenue i Stockton, California 95205 i T209 468-3420 2 464-0138 1 www.sjcehd.com EHD 29-0104-20-23 ) y l lob 1 IF Site Mitigation Wes Permit Applicetion T