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S A N J O A Q U I N 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 andfor 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/stateizip 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/Statelzip Lafayette, CA 94549 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street citylstate/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: O#site BodngsWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORINGOEPTH ❑BOLTEOTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VepodWaler) ❑ RAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTILEVELWELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORIRG ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Body Dla: CwkV Dla: Casing Depth: ❑ INJECTION IAFsorae.Q l ❑ HANDAUGER GROUTSFALDEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHETL GROUTSEAL PUMPED? ❑Yes ❑No (Note:Madmunn Freefall Depth Is30R WELUSOIL BORING IOs GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPM #WELLS TO BE DESTROYED 1 [1 OVER-BORE DIAMETER of_Inches to depth of feel WELL IDS RMW-3 ®PRESSURE GROUT To depth of 30 feel below surface GROUT SPECIFICATIONS Neat Cement - [I EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED []AUGERS []HOSE ®PIPE ®MUSHROOM CAP 03 feet below surface or feel below surface if>3 feet COMMENTS: Lat, Long: 37,82619, -121.2693 I 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 Title/Company Project Engineer; EKI Environment&Water, Inc. Pdnt Name Sam Cronin Date 06/14/2024 DEPARTMENT USE ONLY 1.1 Application Accepted By: rr» Date Issued: 1 20 2 Grout Inspection By/Dates: Destruction Inspection By/Dates: Z Facilll /Site Information FA Name M Alt fwo rk A FA Address q O To , j no_ FA# PR# FA PE 1 2 Cf 6'5 WP Reviewed By —,I-1ik/ Work Plan Dale 5 ,\A_ 7 p 2-4 ❑057 ❑A7 Authoization I&Olev to Sign Permit ❑Workers Comp 11W0efs Camp Wavier ❑Enaaaclunem Permit 59AdesAqreemant p4eWAgeayApproval E6MFR COMMENTS/CONDITIONS:P,Vj.J,.r-e, ro p� {..e, er-y, C6 f o.Sf.Q,Sf (fy� „p�wttt� If Cl,p;r\ rI- 2oz3 CT s.t. ; - a.yirit .tee-far-E jWPTYPEj PE I SC I FEE INFO JAMT REMITTED CHECK#I RECV'D PY DATE WELL PERMIT# INVOICE# Peril W-13 s�G x / W Z Q" / �� i 1868 E. Hazelton Avenue I tockton, California 95205 1 T 209 468-3420 1 IF 464-0138 .s1ce .Co EHO n-0101-2 23 GG>F t g 3 `1'z 5 (., 60 Site MngaVon WeA Pe n lApplication �Q