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SA N J O A Q U I N Environmental Health Department <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 Development Title, Chapter 9-1116.3, and the San Joaquin County Well Standards. <br /> Job Address Lathrop Rd citylstatelzip Lathrop, CA 95330 Phone (650) 292-9062 <br /> Cross Street McKinley Ave APN 198-040-31 <br /> Property owner' Scannell Properties 478, LLC Phone Not Known <br /> Address 3468 Mt. Diablo Blvd. Suite B-115 citylstatelzip Lafayette, CA 94549 <br /> C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 <br /> Address 6821 8th Street city/statelzip 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 citylstatelzip Daly City, CA 94014 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMaler) ❑ HAMMERNRIVEN CIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING OIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes El No BmIng Die: Casbg Die:_Ca*Depth: <br /> ❑ INJECIIONyesmw.c< l EI HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum I'miall Depth is 30 Ft) 1 <br /> WELUSOILBORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYT <br /> #WELLS TO BE DESTROYED 1 ev•Jej ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELLIDs RK-2 ? —V et r=i 4AA "`114�®PRESSUREGROUT Todeplhof 30 feetbelowsudam <br /> GROUT SPECIFICATIONS Neat Cement •tM'ter • Y/G4/u? #EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP 0 3feetbalowsudamor feelbelmsurfamlf>3 feet <br /> COMMENTS: <br /> Lat, Long: 37.82808, -121.2692 <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 /> )DEPARTMENT USE ONLY - <br /> AppilcationAcceptedBy: r'v� Date Issued: <br /> Grout Inspection By/Dates: fl <br /> Destruction Inspection By/Dates: <br /> FacillbrISIte In for ation 11.�. r1 <br /> FA Name U �� � , ' ;gglwrr FA Address , Qut'�SL.. FA# PRO <br /> FA PE C 5 WP Reviewed By Work Plan Date " V pjQ <br /> ❑C-57 0C-57AugWzatlon for Other to Sign Permit ❑WmWsGomp ❑Workers Camp Walwr ❑Encroadimenl Pend) ❑AeoessAgreemenl ❑Lead Agency Approval ❑MFR <br /> L <br /> COMMENTSICONDITIONS: 6� ):,L <br /> ,s.Ge� J,� T'� �t G K �. �-f 1 �'— <br /> C y li'r > d, 20-L 3 Sew:, - O Anwi,�— CT -p- <br /> IWPTYPEI PE I SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT#Brx INVOICE# <br /> Permit $ 2 C zl Z� , P2�-�s 13 <br /> 1868 E. Hazelton Avenue 1 Stockton, a ifornia 95205 1 T 209 468-34201 F 209 464-0138 �www.sjcehdxOm <br /> EHD 2MI 04.20-23 Site Mitlgatim WO Pema Appaeauon <br />