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SAN JQAQUIN 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 wit�an Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address East of Frrreewert�d.(Let 37.84947,LLong: 1213i98) CltyISta ¢ip_Laih CA Phone (650) 292-9062 Cross street Manthey Rd. N 191-270-24 Property Owner' Richland Crossroads, �n V4jt .t6d iw1MS, LI hone (209) 662-5098 Address Not.Known j t7 y,J, TEA Ji�q� L y�, citylstate/zip NQLKTMn /Lkb � .i rl—t-t6,,S-2 C1�r 9S,�q I C-57 Contractor Confluence Technical Services, Inc. License# 1035265 Phone 707-639-7709 Address 6821 8th Street city/state/zip Rio Linda, CA 95673 Consultant/Sub-contractor EKI Environment & Water License# N/A Phone (650) 292-9100 Address 2001 Junioero Serra Blvd Ste 300 City/State/zip Daly City. CA 94014 CONSTRUCTION WORK TO BE PERFORMED:*Note: OHsite BoringsNVells Require Access Agreements or Encroachment Perils TYPE OFWELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ONO BodrODia: Casing Dia: Casing Depth: ❑ INJECTION msome.oiprol ❑ 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) WELDSOIL 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 MW-N4 ® PRESSURE GROUT To depth of 19.75 feel below surface GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From to feet below sudace TREMIE TYPE TO BE USED [I AUGERS [I HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: 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 Date 06/14/2024 DEPA4TMENT USE ONLY n Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information� FAName Vd Afdo pr Al I FAAddress 3 -G FA# PR# FA PE b WP Reviewed By W Work Plan Date ❑G57 57Augorizagon farother to Sign Permit ❑Worker's Comp ❑Worker's Camp Waver ❑EnraOwfiment Permt aess Agreement •0 Lead Agency Approval MFR COMMENTSIC 7DITIONS:� 5 .� µ L 01�— a-At —( rVlq( � riVk�q), �✓t. ,..(n� 7.0 / d�'L �A �i`f SeNI� Q/tl'INa-�. �-e-�® I''� 2.F' G.tt1/'1.✓� L"�f-, VIP TYPE PE SC FEE INFO AMTREMITTED CHElC�K# RECV'DBY DATE ,I/ WELL PERMIT# INVOICE# Permit Q 3 �jp�x CG�2 Cv5 vJ L1jA WpF2g60ILO 1868 E. Hazelton Avenue I Stockton, California 9M5 2�J 468-3420 1 F 209 464-0138 , www.sjcehd.com EHD 2"1 U-20-23 Site Miligaten Well PenAt Applimgun k