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SAN JOAQUIN Environmental Health Department COUNTY— "OvOO, 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 17655 S Manthey Rd citylstate/zip Lathrop, CA 95330 Phone (650) 292-9062 Cross Street Brookhurst Blvd APN 191-190-69 Property Owner- Jess K San ha Phone NU own Address N own �cjZ 0. City/State/Zip NotXR6wn t' 4 Cs,✓ G� ; :��z C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street citylstatelzip Rio Linda, CA 95673 ConsultanUSub-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: OffsHe BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASI FIGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Die: Casing pa: Casing Depth: ❑ INJECTION(AtSoarae.Oaanel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS MWM-8 OPRESSUREGROUT Todepthof 21 feelbelowsudace GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE ® PIPE ®MUSHROOM CAP ®3 feel below surface or feet below surface if>3 feet COMMENTS: Lat, Long: 37.80056, -121 .3007 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 Protect Engineer; EKI Environment & Water, Inc. Pdnt Name Sam Cronin Date 06/14/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Zo2� Grout Inspection By/Dat s' Destruction Inspection By/Dates: Facilit /site Information FAName /Vt fir/ FA Address To L� �- FA# PR# FA PE 9 WP Reviewed By Work Plan Date u th_ Z oZ ❑G-57 57 Authorization For Other to%nPPenit�❑Werkets Gaup ❑Workers CompWalver ❑Encrowlment Permit C(Aaess Agreement ead Agency Approval l 1WMFR COMMENTS/CONDITIONS: �jf-ESS W" ( A K► Zw� ;ls d 2oz3GTFs ,, n� �- ► �e�� WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL/PLERMIT# INVOICE# Permit 207- 131 S x / CC �� tl 2� WP 2�iL�01IZ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3�420 1 F 209 464-0138 iAwwww. )s ce d.com 3 EHD 2941 04-20-23 Site Mitigation Well Pemit Application