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r SAN JOAQUIN Environmental Health Department COUNTY Yi 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 W Stewart Rd citylstatelzip Lathrop, CA Phone (650) 292-9062 cross street S Paradise Ave APN 213-630-01 Properly Owner` Califia LLC - Susan Dellosso; Contact Ryan Alameda for access Ralameda@cambaygroup.com Phone (209) 879-7900 Address N nown ,?�- 0. Sk2-1r.1Q..r4— CKy/statelzip Not-ICf10wfn C-57 contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street cityistatelzip 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: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERNRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes []No Boning Dia: Casing DIX Casing Depth: ❑ INJECTION IAFsname.Ozma1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: ❑AUGERS ❑HOSE El PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum FreaWl Depth Is 30 Ft) WELOSOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DEt TROYED 4 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs MWR-10, MWR-fl, MWR-31, MWR-32 OPRESSUREGROUT TodepthofsCommenls feet below surface GROUT SPECIFICATIONS Neat Cement [1 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [I AUGERS []HOSE ®PIPE 0MUSHROOM CAP 103 feetbelow surface or feel be[=surface if>3 feel COMMENTS: Pressure Grout Depths (MWR-): 20' (10), 20' (11), 22' (31), 22.3' (32) Let, Long (MWR-): 37.81734, -121.3743 (10); 37.8033, -121.3649 (11); 37.80525, -121.3705 (31); 37.80638, -121.3629 (32) I 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 J Date 06/14/2024 Application Accept %ed By: 7— DEPARTMENT USE ONLY Date Issued: Grout Inspection By/Dales: Destruction Inspection By/Dales: Facilit ISite Information FA Name R VJ M d'AO V fkbO^AA FA Addmss O O FA# PR# - FA PE 21 6 WP Reviewed By - �— Wok Plan Dale ❑G57 GS'Authodation for Otherto Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Frluoac ent Permil ❑ArcessAgreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS: '/, O ,w w- IT C; v ♦ t�j[� �� WP TYPE PE SC w FEE INFO �JAAMT REMITTEDI CIHECK# I RECV'D BY PAT WELL PERMIT# INVOICE# Permit CC vJ 2f 'LEI W? 24-00I0$ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-013P 1 WWW.SJC T .c'om EHD29{01 011-20-23 Site Mitigation Well Permit Application �J I r