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SAN JOAQUIN <br /> 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 'to San Joaquin County Develonp��nent Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 1487 nila Rd. W Maflil4 <br /> r City/5tatelZip LafhroR, CA 95330 Phone (650) 292-9062 <br /> Cross Street Menthe Rd. APN 191-270-33 C a(s- -"Q, 0%4 <br /> Property owner Richland Cr ssroads, L.P. Y p.e n y ;,P-w ywd Phone (209) 662-5098 <br /> Address NOtt. nown 130 W . tNgZ+a_ ' Cuy/Statelzip Not-K-W n Mo�ft+tjr -Ha U&L CA q.1739 <br /> C-57 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street cilylstate/zip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor EKI Environment & Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 City/State/Zip Daly City. CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTELEVELWELL CASING DIN <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Alr oarae.ozonel ❑ HANDAUGER GROUT SFAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Masimum Freefall Depth Is 30 FI) <br /> WELL/SOIL BORING Ins GROUT SPECIFICATIONS <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 feel <br /> WELL IDs MW-N3 OPRESSUREGROUT Todepthof 20 feelbelowsudace <br /> GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS El HOSE ®PIPE ®MUSHROOM CAP I0 3 feel below sudace or feet below surface if>3 feel <br /> COMMENTS: <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 Tille/Company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Sam Cronin Date 06/14/2024 <br /> '�\ -DEPARTMENT USE ONLY �7 <br /> Application Accepted By: - Date Issued: � 1 S /< 6 2 - <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FAName � FA Address 3 C j p PJ � FA#( PR# <br /> FA PE ZA b� WP Reviewed By W Work Plan Date ✓yy�j� Z Q <br /> ❑C-57 {AC-57AulhodullonforOlherto Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agree enl Lead Agency Approval RIMER <br /> COMA /CONDITIONS: /J C Q r N G MA 2Q <br /> WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 1 $�X C 5 6 WZ0{-0o cc 21 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468- 42D 1 F 209 464-0138 JAwvTsjcehd.com <br /> EHD29­010,1-20-23 Site Mifigetion Well Per tApplication <br /> S <br />