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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 Lathrop Rd City/State/Zip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street McKinley Ave APN 198-040-29 Property Owner* Scannell Properties 478, LLC Phone Not Known Address 3468 Mt. Diablo Blvd. Suite B-115 City/State/Zip Lafeyette, CA 94549 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 Borings/Wells Require Access Agrnmm-n+e nr Fnrrnarhmnnt Pnrmlts TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO 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 APPLY) #WELLS TO BE DESTROYED 1 ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs RMW-a ® PRESSURE GROUT To depth of 30 feet below surface GROUT SPECIFICATIONS Neat Cement ElEXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ® PIPE ® MUSHROOM CAP ® 3 feet below surface or feet below surface if>3 feet COMMENTS: Lat, Long: 37.82499, -121 .2692 1 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 t DEPARTMENT USE ONLY Application Accepted By: Date Issued: /( -7—Z�2q Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information, FA Name �.;� ¢�/ An�-,� FA Address FA# PR# FA PE r� WP Reviewed By Work Plan Date " ) ❑C-57 P C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver [:] Encroachment Permit Wccess Agreement q,-4ad Agency Approval FIR COMMENTS/CONDITIONS: SS � Oil I � IF, � � m-er - c>�. Z-w`y �irvlait iC�R�� 'I v A �c��G �' r� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $156 x r , 1868 E. Hazelton Avenue Stockton, California 95205 T t209 468-3420 1 F 209 464-0138 NWVV.Sjcehd.dom EHD 29-01 04-20-23 Site Mitigation Well Permit Application