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°U'" SANsJOAQUIN Environmental Health Department <br /> COUNTY <br /> - <br /> -1 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 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 15011 N Davis Rd !>L Ii Ott)\) City/State/Zip Lodi. CA, 95242 Phone N/A <br /> Cross Street STATE ROUTE 12 APN N/A to»i-L.r J1S I A D l� <br /> Property Owner* San Joaquin County(well on county proDerty) Phone N/A <br /> Address _N/A(Encroachment permit application submitted) City/State/Zip N/A <br /> C-57 Contractor Confluence Technical Services License# 1035255 Phone (916)760-7641 <br /> Address 6821 8th St. City/State/Zip Rio Linda, CA 95673 <br /> Consultant/Sub-Contractor Clay Sorensen(West Yost) License# PG#9605/CHG#1108 Phone 831-706-5135 <br /> Address 2235 Mercury Way. Suite 105 City/State/Zip Santa Rosa/CA/95407 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ❑ HOLLOW STEM BORING DEPTH 60 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 in [3 MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA N/A <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 2 in TYPE OF CASING: ❑STEEL O PVC ❑ OTHER N/A <br /> ❑ SOIL BORING 13 PUSH POINT(GP/CPT) CONDUCTOR CASING ®Yes 0 No Boring Dia: Casing Dia: Casing Depth: N/A <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 28 ft TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE EI PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement with 5%Bentonite <br /> DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS []HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <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 Senior Hvdrooeolooist/West Yost <br /> Print Na y Sorensen Date 11/14/2025 <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name I 6 = FA Address Z� ) (�.� �� FA# PR# <br /> FA PE Z WP Reviewed By Work Plan Date t t 1 ; ' <br /> i <br /> -'C-57 ❑C-57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ad Agency Approval ATMFR <br /> COMMENTS/CONDITIONS: Iv iv 1 K 5 I_k lru !v'Iti C'r Lt ,n <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit �`�V r �� $179x �� �c' it li`1•W NZ 3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 ( T 209 468-34�0 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD29-01 07-01-2025 ;L(I �I C;A 1 ­5 Site Mitigation Well Permit Application <br />