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S A N J O A Q U I N Environmental Health Department —COUNTY— ",it o��" 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 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 Consultant/Sub-Contractor EKI Environment&Water License# 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 Soarae.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) WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 5 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS MWM-1*,MWM-2,MWM-3,MWM-4,MWM-6 ®PRESSURE GROUT To depth of 21.5*,21 feet below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:1AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: Lat, Long (MWM-): 37.79403, -121.3042 (1); 37.79682, -121.3064 (2); 37.79643, -121.303 (3); 37.79808, -121.3027 (4); 37.80089,-121.3069 (6). 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 Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �drld�C'.CL Title/Company Project Engineer; EKI Environment&Water, Inc. Print Name Emmanuel Fonseca Date 26 October 2023 DEPARTMENT USE ONLY /� C/ L Application Accepted By: Date Issued: Grout Inspection By/Dates: +� Destruction Inspection By/Dates: / `7/ ( 2 Facilit /Site Information FA Name ` � � t I FA# )"7 !-� PR# an FA Address �)- G w[, ,C✓t .� FA PE .-) [ti�,,• WP Reviewed By -'"�1.1� Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver Q Encroachment Permit ❑Access Agreement ❑ c Lead Agency Approval ElMFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT`REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $ GX ?`� i. i< <� �'� p f) qt(J�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 r f-1 3- 1 , 1, Site Mifigation Well Permit Application