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SAN JOAQUIN Environmental Health Department ------COUNTY Greotness 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 15340 McKinley Ave (Lat: 37.82008 -121 2716) City/State/Zip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Park St. APN ,98-060-16 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 Consultant/Sub-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 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(Vapor/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL 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 RMW-4 ❑ PRESSURE GROUT To depth of 31 feet below surface GROUT SPECIFICATIONS Neat Cement ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ® PIPE ® MUSHROOM CAP ® 3 feet below surface or feet below surface if>3 feet COMMENTS: The mushroom cap will be excavated 22 inches wide and 3 feet below surface. 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 Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY Application Accepted By: ! Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name ,`V„ _�� FA Address t� ; y, FA# �� PR# FA PE �� WP Reviewed By Work Plan Date ;r ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit tlAT C) 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-20-23 Site Mitigation Well Permit Application