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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 17681 S Howland Rd citylstate/zip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross street D'ArCy PkWy APN 19801032 <br /> Property Owner* City of Lathrop Phone (209) 941-7430 <br /> Address 390 Towne Centre Drive city/state/zip Lathrop, CA 95330 <br /> C-57 contractor Confluence Technical Services Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street City/state/zip Rio Linda, CA 95673 <br /> ConsuitanVSub-contractor EKI Environment & Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/Statelzlp Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELIJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Va"Maef) O HAMMERORIVEN DIAOFBOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE O MUDROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Ola: CWgDid: Casing Depth: <br /> ❑ INJECTION fmscxoe.0,mel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS (I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes []NO (Note:Madmum Freefal Depth Is30 FQ <br /> WELL/SOIL BORING me - GROUTSPECIFICATIONS <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 KMW-9 ❑PRESSURE GROUT To depth of 30 feet below surface <br /> GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOMCAP 03 feet below surface or feet below surface 9>3 feet <br /> COMMENTS:Coordinates (Lat, Long): (37.80081, -121.2774), On the side of the street. The mushroom cap <br /> will be excavated 20 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 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: Date Issued: If Z3 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: . <br /> Facili /Site Information <br /> FAName VdArtr M1J p 4f*U FA Address I D -re X"- 2 FA# L � Z PR# p l> V) <br /> FA PE Z b 5 WP Reviewed By LAIJ Work Plan Date 1 0 Ct 2_C) e—3 <br /> ❑C37 57AuUoNzaUwlorOther(o Sign Pamll Oworkees Camp ❑Workers Comp WaNa gEnmachmentPermit ❑Aooess Age eat -, Lead AgemyApprova MFR <br /> COMMENTSICONDITIONS: <br /> I <br /> JWPTYPEJ PE I SC I FEE INFO JAMT REMiTTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 2p0 Z 3 ' 1161 K I CC vJ I I 9 lO L Vj <br /> P00 L4 S05-W <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 www.sidehd.com <br /> EHD 29-01 04.20-23 �y_ Sile Miegaaon Well Permit Applimdan <br />