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SQNdQQQUIN Environmental Health Department <br /> . _ . <br /> COUNTY <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance With San Joaquin County Develll pmenI Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address Golden Valley Pkwv 1.!f 5'0 (7bl� I, I, <br /> Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street Land Park Dr API 19 //4 Q $ iQ <br /> Property Owner* Saybrook Fund Advisors, LLC. (Jeffery Wilson) AI56 �cArOP LAA *f,4iSj'f4A,6LC Phone (650) 632-4522 <br /> Address 303 Twin Dolphin Drive CitylState/zip Redwood Shores, CA 94065 <br /> C•57 contractor Confluence Technical Services, Inc. License# 1035265 - Phone 707-639-7709 <br /> Address 6821 8th Street city/state/zip Rio Linda, CA 95673 <br /> Consultant/Sub-contractor EKI Environment & Water License# N/A Phone (650) 292-9100 <br /> Address 2001 Junipero Serra Blvd Ste 300 city/state/zip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offslte BoringsAAfells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMa(ef) ❑ HAMMERIORIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT[GPI CPT) CONDUCTOR CASING [I Yes ❑No Boring Dlo: Casing Die: Casing Depth: <br /> ❑ INJECTION(A sp".Ozaiel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE - <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Nate:Maximum Freefall Depth is 30 Fill <br /> WELU SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> At WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL IDS CLSP-11 OPRESSUREGROUT Todepthof 22 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement El EXPLOSIVES From_to feet below surface <br /> THEME TYPE TO BE USED [I AUGERS [I HOSE ®PIPE ®MUSHROOM CAP 03feelbeiowsurfaceor feet bet=surface if>3 feel <br /> COMMENTS: <br /> Lat, Long: (37.822074, -121 .296488) <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project Engineer; EKI Environment & Water, Inc. <br /> Print Name Sam Cronin Date 06/14/2024 <br /> pEPARTMENT USE ONLY l t/ <br /> Application Accepted By: //(J drw Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facill /Site Information <br /> FANeme yJ AID FAAddress 0 WA.J --, I FA# PR# <br /> FA PE 2Ci S WP Reviewed By Work Plan Date <br /> ❑G-57 57Authoflzagonfor0therto Sign Permit ❑Workers Comp ❑Workers Comp Waive) 4ZwInoontTPermit Access Agreement al(AgencyApproval ZL,AFR <br /> COMMENTSfCONDITIONS: MISS �K C ray ytSS-?SS ' ih .+y <br /> at r C/La:nd- 7rjo23 Stwti 'oLA/► G171 ' e-eee <br /> WP TYPE PE I SC FEE INFO JAMTREMiTrEDI CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> —d <br /> Permit ��d 3(3 �5 X Cq+G - �t{ K/f Zk"ooIZS6 <br /> 1868 E. Hazelton Avenue tockton, California 95205 �09 46 -34 0 I F 209 464-0138 P ww sjc€h COm <br /> EHD 2944 N20-23 Site Mitigation Well Permit Application 4 <br /> 1 <br />