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SAN JOAQUIN 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 9-1115.3, and the San Joaquin County Well Standards. Job Address Stewart Rd city/Statefzlp Lathrop, CA Phone (650) 292-9062 cross street Dell'Osso Dr APN 2 3-61D-72H 213 610 y-9 Property Owner- Califia LLC - Susan Dellosso; Contact Ryan Alameda for access Ralamedapcambaygroup.com Phone (209) 879-7900 Address Ngt_K-rt6Wn --p 3 VJ- Ste` o,-r-L citylstatelzip No � hr- C-P, '15-S30 < V:j C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street citylstatelzip Rio Linda, CA 95673 Consultant/Sub-contractor EKI Environment & Water License# N/A - Phone (650) 292-9100 Address 2001 Junipero Serra Blvd Ste 300 citylstatelzip Daly City, CA 94014 CONSTRUCTION WORK TO BE PERFORMED: *Note: OfTslte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSYEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI LEVEL WELL CASING DIN ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPEOFCASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Berea Dix: Caft Dla: cwkg Depth: ❑ INJECTION(AFseaae.o:caret ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Marrnum Freelall Depth Is 30 F1) WELL/SOIL BORING IOs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE ORMETER of_Inches to depth of feet WELL IDS MWR-5R MPRESSUREGROUT Todepthof 90 feelbelowsurfece GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE M PIPE M MUSHROOM CAP M 3 feetbelow surface or feel below surface if>3 feet COMMENTS: Lat, Long: 37.79571 , -121.3459 j 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 �� THWCompany Project Engineer; EKI Environment&Water, Inc. PdntName Sam Cronin Date 06/14/2024 I DEPARTMENT USE ONLY Application Accepted By: Dale Issued: - - ) 5 / 2 a 24 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facllil /Site Information FA Name M yY! {.rV,lp r FA Address I 0 FA# PR# FA PE 29 WP Reviewed By Work Plan Dale r-g_ Z4' ❑C-57 C-57Authodserion("(Other to Sign FWmll ❑VIteWsOamp ❑Workers Comp Waiver ❑Enaroxelsnenl Permit [%koenAgreement PZLead AgeneyAppmval IXMFR COMMENTSICONDITIONS: ?(Uj;tA,hQi t) 0�'t K L a.S d, ZOzc3 CT F s ewt't cwt Q. r WP TYPE I PE I SC FEE INFO AMT RE[VnTEDJ CHECK# RECV'D BY DAT WELL PERMIT# INVOICE# Permit Abe $ \ �, CC -'W � Z� wP '400118 to C 1 sa 2s 8 2 DO,5 1868 E. Hazelton Avenue tockton, alifornia 95205 T 209468-3420 1 F 209 464-0138p'y WWW.sjceh .com EHD2MI 04.20-23 Site Mldgadon Wek PenAt Applicason /A a