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t �pUl/y C S A N _J O A Q U I N Environmental Health Department --COUNTY o�cIFpw�'`P Grp- prow SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z4 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 dies Rd. 2'30L VJ /fN^5�fev^y (r'�City/State/Zip Lodi. CA. 95242 Phone N/A Cross Street Armstrong Rd. APN 05523029 Property Owner" San Joaauin Countv(site is in right-of-wav) Phone N/A Address N/A City/State/Zip N/A 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 (925)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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N/A ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE 0 EXTRACTION(VaporMater) 0 HAMMERIDRIVEN DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL BORING 9 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑o Yes 0 No Boring Dia: Casing Dia: Casing Depth: 0 INJECTION(Air Searge.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 1 ❑OVER-BORE DIAMETER of N/A inches to depth of N/A feet WELL IDs WSM-11 �PRESSURE GROUT To depth of 50 _feet below surface GROUT SPECIFICATIONS 0-5%Bentonitedey,&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 [I AUGERS ❑HOSE E]PIPE 5j 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 SaJoaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed ___ _ _Title/Company Senior Hvdrooeolocist/West Yost Print a e Clay Sorensen Date 10/22/2025 DEPARTMENT USE ONLY Application Accepted By: _ Date Issued: l L Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name `= FA Address �] 7 i I N>ti� �� FA# PR# Dq�> FA PE a!, ) WP Reviewed By ZZ Work Plan Date 11 l J, ] hr-57 ❑C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement EK*ad Agency Approval FR COMMENTS/CONDITIONS: 1-w D4 7jcv2v� 6l 4-f- r WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit lv'Z '/j�3 $179x Llq v LL 11�(��1) WP250133 I Alf 1868 E. Hazelton Avenue I Stockton, California 952051 T 209468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 �L t I `I I, 13 Site Mitigation Well Permit Application