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SAN JUAQUIN Environmental Health Department COUNTY— 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 775 W Manila Road city/state/zip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Manthey Rd. APN 191-260-25 Property Owner' Linda Phen Phone (209) 470-1325 Address Not Known gS0 W-A*.rc Lit, SteI1 city/stale/zip Not Known o C jQ 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 Boring&VVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEOTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapwM'ater) ❑ HAMMERrORIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) GONDUCTORCASING ❑Yes [I No Boning Dia: Casing Dia: Casing Depth: ❑ INJECTION faseage.ozwrol ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madmum Freefoll Depth is 30 Ell WE W SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feet I, WELLIDs NMW-3 ®PRESSUREGROUT Todepthor 20 feetbelowsurfam GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feet below surface THEME TYPE TO BE USED ❑AUGERS [I HOSE ®PIPE ®MUSHROOM CAP ®3 feel below surface or feet below surface if>3 feet COMMENTS: 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 DEPARTMENT USE ONLY r Application Accepted By: Date Issued: 1J ,2 d Grout Inspection By/Dales: Destruction Inspection By/Dates: 12-1 Facilil /Site Information ^ n FA Name Vj'eW0* FAAddress O Q FA# I PR# FA PE 2°t WP Reviewed By ork Plan Date 0G57 G57 Aullwdzatlon for Other lo Sign Permit ❑Workers GanD ❑WoAcers CompWaNer ❑Erimoachment Permit Agreement geoW Approval FR COMMENTS/ 0 ppITIONS: ptAt#L or GV1s: r. �ncZt1� (`jS�•t�i — hnk�C.. V " o WP TYPE n PE I SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit (�q� J� L$ ;2 C. J 21 t 4'� 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 4 8- p 4420 1 F 209 464-0138A1 wLww.sjcehd om EHD 29-01 N-20-23 C C A 143 14 Z j v e Site Mitigation Weil Penult Application 3