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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 2100 Stewart Rd citylstatelzip Lathrop, CA 95330 Phone (650) 292-9062 cross street Lakeside Dr APN 213-250-04 Property Owner' Califia LLC - Susan Deilosso' Contact Ryan Alameda for access Relameda@cambaygroup.com Phone RNL87 Address Not Knoyv�n� -- r3 W - S �CuJ aKt✓ citylstatelzip No own ) C A 9S 33o �tN C-57 contract CooF niluence Technical Services, Inc. License# 10 5255 Phone 707-639-7709 Address 6821 8th Street cuyistateizip Rio Linda, CA 95673 ConsultantISub-contractor EKI Environment &Water License# N/A Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 citylstate/Zip Daly City. CA 94014 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsile Bormg&NVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACRON(Vapor/'Naler) 13 HAMMER,DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASINGTHICKNESS TYPE OF CASING: El STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPICPT) CONDUCTORGASING []Yes ❑No Bairg Dia: CWkg Dla: Caskq Depth: ❑ INJECTIONINrswo.Ozanel D HANDAUGER GROUTSFALDEPTH TREMIETYPETO BE USED: [I AUGERS ❑HOSE ❑PIPE - ❑ OTHER ❑ OTHER GROUTSEALPUMPED? ❑Yes []No (Nole:MadmumFreefall Depth Is30Fg WELU SOIL BORING IDs GROt1rSPEGHGATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) #WELLS TO BE DESTROYED 1 [I OVER-BORE DIAMETER of_inches to depth of feet WELL IDs MWR-4 ®PRESSURE GROUT Todepthof 20 feelbelowsudam j GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to_feet belay surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 03 feel below surface or feet below surface if>3 feet COMMENTS: Lat, Long: 37.79061 , -121.3362 j 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 /�I pEPARTMENT USE ONLY Application Accepted By: Y V Dale Issued: Grout Inspection By/Dales: Destruction Inspection By/Dates: 4✓L 7-17 FaclIlIvISIte Information FA Name e��j,J FA Address �(Q D lAI&_Q FA# PR# FA PE WP ReNewed By Wak Plan Dale �N r L ", ❑057 y057AUUodzatianforOLherIoSignPermi1 ❑Workers Camp ❑Workefscomp Walver ❑Encroachment Pardt ❑Access Agreement D( eadA9emyApprovzl MFR COMMENTSICONDITIONS:O)/ �D - P re5s�.�0 rd� Qyt 6L dr 2023 C,,Tk5 owncuLQ- r� WP TYPE I PPE I BC I FEErNFO JAMT REmTTTEDj CHECK#I RECV'D BY I DATE 1b �A1 WELL PERMIT# INVOICE# Permit ?.q Z' 3 $1 X - lit/ ` W 2VC0 I 1' - 183 4 7 1868 E. Hazelton Avenue j t tockton, (350ornia 95205 1 T 209 468-3420 j F 209 464-0138 j www.sjcehd.com EHD 2e-01 04-M23 eXl A Slle Mlegabon Wee Pemit Applimilon , I r�-