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SA N J OAQ U I N 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 94115.3, and the San Joaquin County Well Standards. Job Address Lathrop Rd Cilylstatelzip 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/State2lp Lafayette, CA 94549 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street clly/statelzip Rio Linda, CA 95673 ConswtanUSub-Contractor EKI Environment& Water License# N/A Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 citylstate/zip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agri= f- P=/mils TYPE OFWELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXrRACTION(VapouWater) ❑ HAMMEWRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING mA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CAGING [I Yes ❑No Boring Dia: Cashg Dia: Caring Depth: ❑ INJECTION(AYSaaa.m,raa ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:MalhnumFreefall Depth Is30Fit WELLISOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALLTHAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of—Inches to depth of_feet WELL IDs RMW-2 ®PRESSUREGROUT Todepthof 30 festbelowsudace GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From to_feetbelmsudace THEME TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feel COMMENTS: Lat, Long: 37.82999, -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 Data 06/14/2024 DEPARTMENT USE ONLY 2 - Application Accepted By: Dale Issued: Grout Inspection By/Dates: Destruction Inspection By/Dales: Fac111 ISI a Information, I - I _ FA Name A I FAAddress 7.T0 In FA# PR# FA PE 5— WP Reviewed By Work Plan Date y- AL Z a ❑C57 57AuU*dM0Mfoo0wbSign Permit ❑Wohzrs Comp ❑workers Oomp Waiver ❑Emoaclerml Permit ccessAgreemenl Dyad AgenyAppmvel Q4FR COMMENTS/CONDITIONS• �1�- �Ss P"ryta;l ChRrh� �2v �se�t a r(nuaJC CTr t2ff rf • �"4 Gy WP TYPE PE sC I FEE INFO JAMT REmUTTED1 CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit qD 1,3 $158x Z INQ24001 2 1868 E. Hazelton Avenue Sfockt0n, California 95M T 209 468-34201 F 209 464-0138 w ww.s cehd.dZmn 2 END 2"104- 23 Site Mlaoelim Well Permit Applleat[w