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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 chyistatelzip Lathrop, CA Phone (650) 292-9062 Cross Street MCKinley Ave APN 198-040-28 Property owner- Scannell Properties 478, LLC Phone Not Known Address 3468 Mt. Diablo Blvd. Suite B-115 City/stateizip Lafayette, CA 94549 C-57 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street cityistateizip Rio Linda, CA 95673 Consultant/Sub-Contractor EKI Environment & Water License# N/A Phone _(650) 292-9100 Address 2001 Junioero Serra Blvd Ste 300 City/State/zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsile 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 fVaporNalen ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING ON ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSHPOINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dla: Casing Dia: Caskg Depth: ❑ INJECTION Waorae.Oraul ❑ HANDAUGER GROUTSEALDFPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER GROUTSEAL PUMPED? ❑Yet ❑No (Note:Madmum Freefall Depth ls30 Fp WEW SOIL BORING IDs GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL We RMW-3 OPRESSUREGROUT Todepthof 30 feel below surface GROUT SPECIFICATIONS Neat Cement - ❑EXPLOSIVES From lo_feetbelowsudace TREMIE TYPE TO BE USED (I AUGERS [I HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feet balm surface If>3 feel COMMENTS: Lat, Long: 37.82619, -121 .2693 1 hereby certify that 1 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 Tltle/Company Project Engineer; EKI Environment&Water, Inc. PMt Name Sam Cronin Date 06/14/2024 DEPART ENT USE ONLY t�, Application Accepted By: 0-» Date Issued: 1 Zo / Grout Inspection By/Dates: Destruction Inspection By/Dates: 44Z FaCINI ISlte Information FAName M Vt4oarV- AvAdAFAAddress qO To vJ P-4— FA# fA FA PE I 2 Cf 6 ✓J WP Reviewed By --;S-w I Wak Plan Date Z O,�/�2� .4 ❑C-57 ❑ AUTAodraOunforOthertoSlgn Permit ❑Workees Comp ❑Wakens CanpWahw ❑Encroachment Permit A=sA9reemen1 OkeWAgencyApproval C9MFR COMMENTSICONDITION3:PrvjJ,a,,-e, ro ok— 4,. xr, - � J ck, ;l < t- Zoz,3 C? � - an et reP°� F WP TYPE I PE I SC I FE INFO JAMT RENIn-TED1 CHECK#I RECV'D Y DATE/ WELL P��ER�kMIT# INVOICE# Permit ls1fi X U w ,,p Z--�� 1868 E. Hazelton Avenue I tockton, California 95205/1 T 209 468-34201 F 209 464-0138 1 'WrAw sjce .co " EHO 29ol 04-20-M CC V t G 3 4IZ 5 (C 619 site Mlegaaon Well PamllAppllcauon /P