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SAN JUAQUIN Environmental Health Department COUNTY— .,,rOW,vo 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 9-1116.3, and the San Joaquin County Well Standards. Job Address 601 Tesla Dr city/state/zip Lathrop, CA 95330 Phone (650) 292-9062 Cross street Christopher Way APN 198-220-10 Property Owner* BPP PAC Industrial CA REIT Owner 2 LLC Property Manager: Jacque Harris Phone (510)407-3695 Address PO Box 847 City/StatelZip Carlsbad, CA 92018 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 BoringsNJells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING OEM ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapor/'Naler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AtSwo.0mne1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO 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 APPLYI #WELLS TO BE DESTROYED 1 El OVER-BORE DIAMETER of inches to depth of feel WELL IDs KMW-2 OPRESSUREGROUT Todepthof 30 feet below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP Ea feet below surface or feet below surface if>3 feet COMMENTS: Lat, Long: 37.79967, -121 .2896 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 Dale 0 6/1 412 02 4 D PARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dgba Destruction Inspection By/Dales: Faclli /Site formation r FA Name -1 pot FA Address 0 FA# PR# L FA PE j WP Reviewed By Work Plan Dale ❑G-57 j1 G51Auttrorinfion for Otherto Sign Permit ❑Workets Camp, ❑Workers Compwalwr ❑Eremachment Permit Wooess Agreement IeWWAgencyApproval I WFR COMMENTS/CONDITIONS: �` — 69 c5r— Gh cN„Q_ Zo 2-3 544. Rnnw1 GTF r-l1r/T/T-- WP TYPE PE SC fEE INFO JAMT REMrrTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 4 I x 19 1, Z G�� 24 �14 Z.40o 135 C 3 Q 1868 E. Hazelton Avenue I S ockton Califdrnia 95105 S I T 209 468-3420 1 F 209 464-013 r WwW6S4 a%d..cOm EHO 29-01 04-20-23 Site Mitigator,Well Pemil Application t