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SAN JOAQUIN Environmental Health Department <br /> ) COUNTY <br /> . +_�p / <br /> r..1 Greotness 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 with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address De Lima Rd. (Lat: 37.83805, Long: -121.3107) city/state/zip Lathrop, CA Phone (650) 292-9062 <br /> Cross Street APN 19 420-64 <br /> Property Owner' Sam Chahal 0,Ro.kt Sur :i 1�S h & Phone (209) 483-2324 <br /> Address 2217 Coffee Rd. city/Staterzip Modesto, CA 95242 <br /> c-57 contractor Confluence Technical Services, Inc. License# 1035256 Phone 707-639-7709 <br /> Address 6821 8th Street cityistateizip 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 cityistateizip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTEDTRAFFICBOX ❑STOVE PIPE <br /> ❑ EXmAcnoN(vapormater) ❑ HAMMERfamvEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS[I MULTTLEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boflng Dia: Gazing Be: Cssiig Depth: <br /> ❑ INJECTION KVSP oe.Oime) ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IN GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALLTHATAPPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs CLSP-9 OPRESSUREGROUT Todepthof 16.5 feetbelmsudace <br /> GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From to feet below sudace <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE ®PIPE ®MUSHROOM CAP ®3 feel below surface or feel 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 Title/Company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Sam Cronin bate 06/14/2024 <br /> / EPARTMENT USE ONLY <br /> Application Accepted By: ✓ Dale Issued: -7- 24- <br /> Grout Inspection By/Dates: V Is <br /> Destruction Inspection By/Dales: <br /> Faclli /Site Information <br /> FA NameIAJW W# FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date n„(L <br /> ❑CG57 0057AWroftaflon for Otherto Sign Permit ❑Workers Gomp ❑Workers Camp Waiver ❑EnaowhmentPermit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COM MENTSICON DITIONS: <br /> WP TYPE I PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DAT WELL PERMIT# INVOICE# <br /> Permit q t)`61 3013?56 x 1 L a <br /> C C s � 9 w f- q-oo 1 2,5- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205�T 209 468-3420 I F 209 464-0138 1 VaW w.sjcehd.com <br /> EHD 29d1 04-20-23 Site Mitigation Well Peed/Application <br /> 4 <br />