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1 <br /> ;QUA ". , � OAQUINSAN, Environmental Health Department <br /> COUNTY-- <br /> c�crFoa`P' Greatness crows herd <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 4251 W Tredwav Road City/State/Zip Lodi. CA.95242 Phone N/A <br /> Cross Street N Ray Rd. APN 05518001 <br /> Property Owner* San Joaauin County(site is in riaht-of-wav) Phone N/A <br /> Address N/A City/State/Zip N/A <br /> C-57 Contractor Confluence Technical Services. Inc License# 1035255 Phone (916)760-7641 <br /> Address 6821 8th St. City/State/Zip Rio Linda. CA 95673 <br /> Consultant/Sub-Contractor West Yost Associates License# CHG#1108 Phone (925)949-5817 <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 WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NIA <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑a Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) Cl HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ®No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of 8 25 inches to depth of.9 feet <br /> WELL IDs WSM-10 RPRESSURE GROUT To depth of 4_feet below surface <br /> GROUT SPECIFICATIONS 3-5%aentoniteclay,0-10gallonsofpotablemterpersackofPortlandcement. EXPLOSIVES From N/A to NIA feet below surface <br /> TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE El 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 Hvdroaeoloaist/West Yost <br /> Print N e lav Sorensen Date 10/22/2025 <br /> DEPARTMENT USE ONLY l <br /> Application Accepted By: Date Issued: 1 1 l I <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FAName �1� ilvu �n W FA Address •T-K V, A# PR# ()'j l s3v6 <br /> FA PE WP Reviewed By Work Plan Date `1 '5 <br /> 57 ❑C-57 Authorization for Other to Sign Permit orkees Comp ❑Worker's Comp Waiver §kncroachment Permit ❑Access Agreement ''!-Lead Agency Approval 12rMFR <br /> COMMENTS/CONDITIONS: r� D­1yV ri �U� 5 r <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECYP BY DATE WELL PERMIT# INVOICE# <br /> Permit U50133,3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 2 y1 r t 1351 Site Mitigation Well Permit Application <br />