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1 QUIN�. �2�°P-�-'�c°z SA N._J 0 A 0 U I N Environmental Health Department Its ` COUNTY `cFORa`r Greatness grows her, 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 11501 Thornton Rd City/State/Zip Lodi, CA, 95242 Phone N/A Cross Street Frontage Rd. APN 05512006 Property Owner* State Wildlife gefuae(Overseen by Jake Aucelluzzo) Phone (530)757-1813 Address 11501 Thornton 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/StatelZip 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 WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N/A ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING ®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) WELU 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 R 25 inches to depth of .5 feet WELL IDs_WSM-13 Fo&PRESSURE GROUT To depth of 9n feet below surface GROUT SPECIFICATIONS 3-5%Bentonite clay,8-10 gallons ofpowblemter per seckofPordendCement EXPLOSIVES From N/A to N/A feet below surface TREMIE TYPE TO BE USED []AUGERS []HOSE [a PIPE MUSHROOM CAP ❑3 feet below surface or S 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 Z Title/Company Senior Hvdroaeoloaist/West Yost Print m Ciay Sorensen Date10/22/2025 DEPARTMENT USE ONLY �t Application Accepted By: Date Issued: Grout Inspection By/Dates: l Destruction Inspection By/Dates: Facilit /Site Information FA Name tA,L-f_ 5LO, -k LV _ FA Address (7 ,--71, �1i 0'r µ—,1 BZ FA# I PR# FA PE `r��j �� WP Reviewed By Work Plan 57 57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp aiver ❑Encroachment Permit ❑Access Agreement ead Agency Approval ,(UFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit V10Z 3 X 3 $179 x `—)-kl (—C t 1,- 5 133 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4F8-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-01 07-01-2025 �t t 6 t ` 115 Site Mitigation Well Permit Application