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SAN JOAQUIN Environmental health Department <br /> 1'. ,. COUNTY— <br /> ,,,r„r,� , 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 With San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 18300 S Harlan Rd City/state/zip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street Christopher Way APN 198-13042 <br /> Property Owner* Centerpoint Properties Trust(Rep. Paul Olarte) Phone (415)205-7551 <br /> Address 180E Swift Drive, Suite A CitylStatelZip Oak Brook, IL 60523 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street city/state/zip Rio Linda, CA 95673 <br /> consultant/Sub-contractor EKI Environment & Water License# NIA 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: ORsite BoringsArVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLUORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMatm) D HAMMERADRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPICPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth. <br /> ❑ INJECTION(AFaoxae.0zme1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: ❑AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fit <br /> WELU 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 feet <br /> WELL IDs MW-5 ®PRESSUREGROUT Todepthof 20 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑HOSE ®PIPE ® MUSHROOM CAP ®3 feel balm surface or feet below surface If>3 feel <br /> COMMENTS: <br /> Lat, Long: 37.79436, -121 .2916 <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 Date 06/14/2024 <br /> DEPARTMENT E ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: , <br /> Facility/Site Information <br /> FAName 0VC �FAAddress 3qo „Jn-Q, FA# PR# <br /> FA PE 6 WP Reviewed By Work Plan Date <br /> ❑G57 1016.9Aulhoriialion for Other to Sign Permit ❑Workers Gump ❑Workers Comp Waiver ❑Encroachment Permit KLmmAgowment ncyApproval FR <br /> COMMENTS/CONDITIONS: /j�3 r-s�r 0tc-- �—L` 'L<i��l, cL,SS CSS '� CLOL <br /> �• <br /> WP TYPE PE I SC F E INFO JAMT REMn­-rED1 CHECK# I RECV-D BY I DATE lI WELLP,E,RMIT# INVOICE# <br /> Permit �Z 313 $ 8x J J 2V' W 2-Ct lv 01 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 l>T 209 468-3420 1 F 209 464-0138A1 wzwww.sjceRd com <br /> EHD 29-01 04-20-23 Site Mugallm Well Permit Application <br /> ►3 <br />