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. S . r �UIIIN ., SANdOAQUIN Environmental Health Department COUNTY i(IFQ ' Greotness 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 18601 Christopher Way CitylStatelZip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Tesla Dr. APN 198-130-62 Property owner CVICH Lathrop I LLC in Care of lBuzz Oates LLC C bil Bryant ranted access Phone (916) 3 9-38009-3800 Address N own 5 S S 4�\S ,' City/StatelZip NDt Known J Ct-k* -�'1f O U W/ C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707- 39-7709 Address 6821 8th Street citystate/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 BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) 0 HAMMERIDRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING El Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTIONrAtsnsva.Ozantl ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freef ill Depth is 30 Fi) WEW SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: ICHECKALL THAT APPLY) #WELLS TO BE DESTROYED 2 ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS KMW-10, KMW-11 OPRESSUREGROUT To depth of_feet belowsurface GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ®PIPE ®MUSHROOM CAP 103 feel below surface or feel belay surface if>3 feet COMMENTS: Pressure Grout Depths (KMW-): 27.5' (10), 27.1' (11) Lat, Long (KMW-): 37.79888, -121.28825 (10); 37.79738, -121.28876 (11) 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 D�TMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dales: FacilltvISIte Informatio JZ FAName Nb FAAddrew 9 O OVA/ FA# I PR# FA PE WP Reviewed By Wak Plan Date ❑G-57 57Auttmrzagon for Other to Sign Perot ❑Workers Cane ❑Workers Camp Warner ❑Encroachment Permit 94pcessAgmement ❑yd Agency Approval R COMMENClL��Ts, LL( DID ter- i,KZ o-sS e 1s s _-ems; l r V 5 en1; anntsAQ GT4= WP TYPE PE I SC FEE INFO JANIT REmirrEDI CHE K# I RECV'D BY I PAT WELL PERMIT# INVOICE# Permit SOB, �33 yyL.. � �t� W�Z� ' 1868 E. Hazelton Avenue I Stockton alifornla 95205 1 T 209 468-3420 1 F 209 464-0138 �`www s cehs5 m �4 EHD 29-01 04-20-M Site Mitigation Well Perini Application