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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 De Lima Rd (Lat: 37.83514, Long: -121.3072) City/state2lp Lathrop, CA Phone (650) 292-9062 Cross Street Manthey Rd. APN192-020-63 Propertyowner' Sam Chahal C C k P(HAL� i T S 1"4W L_J Phone (209) 483-2324 Address 2217 Coffee Rd. City/State/zip Modesto, 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: ORsile BoringsNJells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING El Yes ❑No Wag Na: Casing Dia: Casing Depth. ❑ INJECTION(Akswee.Oiorel ❑ HANDAUGER GROUr SEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feel WELL IDs CLSP-1 OPRESSUREGROUT Todepthof 16.5 feelbelowsudace GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From to_feelbelmsudace TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ® PIPE ®MUSHROOM CAP 0 3 feel 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 0 611 4/2 0 24 PARTMENT USE ONLY ./ Application AcceptedB • Date Issued: T /I -7/ 20Z q[� Grout Inspection By/Da tes: - Destruction Inspection By/Dates: Facili /Site Information FAName JK(/,� U,fpVA tM I FA Address L) /`Q, FA# PR# _ FA PE RJ WP Reviev ed By I Work Plan Date Z 6 0G-57 G57Au0orization for Other to Sign Pont ❑Wodrefs Comply❑Worker's Comp Waiver ❑Encroachment Permit ss Agreement AgerKyyApproval %MFR COMMENTS/C NDITIONS: r yr Ok d- dK ,FKI/� C rla:h r AM&� � 23 S,ewu — a,Y1rtW�JC r✓Tr— r2 PO rt WP TYPE PE 7 SC FFE INFO =1i CH7n+EnCK# RECV'D BY DATE ��f WELL PPeE,RMIT#[�, INVOICE# Permit cjcZ 15 zQl/� ) ryi VJP 4012 IS 1868 E. Hazelton Avenue I tockton, CT 209 468-3420 1 F 209 464-0138 www.vehi: COV EHD 29 01 OT20-23 Site Mitigator,Well Permit Application r