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i 1°— Ar- S A N ,10AQ U I N Environmental Health Department iin COUNTY °.1 "o Greatness crows 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 11400 N Rio Blanco Road City/State/Zip Lodi. CA. 95242 Phone N/A Cross Street N/A APN } p c�e>c"� Property Owner* Robert Kammerer Phone (209)481-1620 Address 11400 N RIO BLANCO RD City/State/Zip Lodi. CA.95242 C-57 Contractor Confluence technical Services. Inc License# 1035255 Phone (916)760-7641 Address 6821 8th St, City/State/Zip Rio Linda, CA 95673 Consultant/Sub-Contractor West Yost Associates License# CHG#9605 Phone (9251 949-5817 Address 2235 Mercury Way, Suite 105 City/State/Zip Santa Rosa, CA. 95407 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N/A ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) 0 HAMMER/DRIVEN DIA.OF BOREHOLE 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING 17 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑o Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Airsoarge.Ozone) ❑ HAND AUGER 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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 2 OVER-BORE -y`% DIAMETER of A 25 inches to depth of 5 feet WELL IDS RMW-2. RMW-3 PRESSURE GROUT To depth of 15 feet below surface GROUT SPECIFICATIONS 3-M Bentonite clay,8-10 gallons of potable water per sack of Portland Cement. ❑EXPLOSIVES From N/A to N/A feet below surface TREMIE TYPE TO BE USED AUGERS HOSE PIPE EjkMUSHROOM 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 114Z Title/Company Senior HvdrooeolooisVVVest Yost Print Na a lav Sorensen Date 10/22/2025 /� DEPARTMENT USE ONLY Application Accepted By: \ Date Issued: ll l Lj�'l Z Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name fir` l k w L — FA Address \�, j UJ. ��1 v�w 4# PR# FA PE WP Reviewed By Work Plan Date IA W57 ❑G57 Authorization for Other to Sign Permit orkees Comp ❑Workers Comp Waiver ❑LEncroachment Permit ❑Access Agreement 19 Lead Agency Approval MFR COMMENTS/CONDITIONS: w 1�5'Ctr r t—D�u4 (l J- W WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV-P BY DATE WELL PERMIT# INVOICE# Permit ��v). �j1� $179x � 7 ?�Jy G (� 11�� Z� Val r 9.501 331 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-31420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 r l L i 1 33 1 Site Mitigation Well Permit Application