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SAN JOAQUIN FnvoronrnienLIA He, Dl(h Department --COUNTY r - 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 1240 W Bowman Rd (Lat: 37.8601, Long: -121.308)City/State/Zip French Camp, CA 95231 Phone (650) 292-9062 Cross Street S Holmes Rd. APN 191-280-09 Property Owner* Bachitar Singh and Jaswinder Kaur Phone (209) 327-2836 Address 2072 Providence Way City/State/Zip Lodi, CA 95242 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 WELL/BORING 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 Sparse,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 2 ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs MW-N 1, MW-N2* ® PRESSURE GROUT To depth of 19,20.5* 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 Application Accepted By: Date Issu d: / /20 I Grout Inspection By/Dates: r g O`er%jC ck Destruction Inspection By/Dates: -"-` W1,V111J 4- N2.. Facilit /Site Information �7 FA Name i , �� FA Address D N,l . FA# PR# FA PE ;� WP Reviewed By Work Plan Date ❑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: Q h � _ /i -�y� y � WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# } Permit 'tjI VL c' 1✓ $156 x c i � �� W 4.'1 VO t L Cr 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 �www.Sjcehd.com EHD 29-01 04-20-23 Site Mitigation Well Permit Application 16