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SAN JOAQUIN Environmental Health Department COUNTY Greoirtess qro vs Isere, SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Flours 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 405 Manila Road City/State/Zip Lathrop CA, 95330 Phone (650) 292-9062 cross Street Manthey Rd. APN 191-260-13 Property Owner* Inder'it Bassi Phone (510) 589-3512 Address Not Known t � F:, ;, <<,,,.t- "` City/State/Zip Not Known` 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# N/A 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(VaporMater) ❑ 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(AirSparae,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: (CHECKALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs N MW-2 ® PRESSURE GROUT To depth of 20 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: 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 Title/Company Project Engineer; EKI Environment & Water, Inc. Print Name Sam Cronin Date 06/14/2024 DEPARTMENT USE ONLY f t Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name MVV V00 FA Address 1 Q U`-� FA# ! PR# c FA PE WP Reviewed By rti Work Plan Date ElC-57 Y7 G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit '❑Access Agreement `Q Lead Agency Approval Y' FR COMMENTS/ ONDITIONS:;J�,."" , /D - O �- jp�t-L.k - �.�,� � 'L„-j �� y 4�y y r 7 fj��ZG�Ii (Eh', ClkOLI'n) (ol- -coA Semi antiu.ck C rtr WP TYPE UPE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit $156 x i ,� 10 _ r .� +lye L �2 �I1�pVto(7 113 1868 E. Hazelton Avenue Stockton, California 95205 1 . 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com T EHD 29-01 04-20-23 �>i;,.{ '�, � `� � F ' Site Mitigation Well Permit Application z