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° SANs10AQUIN Environmental Health Department " _i `j COUNTY— .1 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 7298 W STATE ROUTE 12 City/State/Zip Lodi. CA.95242 Phone N/A Cross Street 1-5 Frontaae Rd APN 05515018 Property Owner* State Wildlife Refuge(Overseen by Jake Aucelluzzol Phone (5301 757-1813 Address 7298 W STATE ROUTE 12 City/State/Zip Lodi. CA. 95242 C-57 Contractor Confluence Technical Services. Inc License# 1035255 Phone (9161 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 BoringsM/ells 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) ❑ HAMMER/DRIVEN 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(Atrsoaras.ozonei ❑ 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-=7*- DIAMETER of A?. inches to depth of 5 feet WELL IDs WSM-19 4L PRESSURE GROUT To depth of 4—feet below surface GROUT SPECIFICATIONS s-5%Bentonite clay,8-10pe0onsof potable mter per sack ofPordandCement. EXPLOSIVES From N/A to N/A feet below surface TREMIE TYPE TO BE USED ❑AUGERS []HOSE E)PIPE &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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Senior Hvdroceoloaist/West Yost Print earrie Clay Sorensen Date 10/22/2025 DEPARTMENT USE ONLY " Application Accepted By: V41 Date Issued: Lt r Z 5 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address 121-5 � � �,�1�0�L2 FA# PR# FA PE -Zot G� WP Reviewed By Work Plan Date k t L2 57 ❑G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement Wead Agency Approval INWFR COMMENTS/CONDITIONS: tvL W 111-5 i - '1i w,-- WP TYPE PE SC FEE INFO AMT REMITTED CHECK# IRECV'p BY DATE WELL PERMIT# INVOICE# Permit T(I(7 $179x V GL �� '� Z VW Pa nI 1868 E. Hazelton Avenue I Stockton. California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 7 it 6 t 0 '+j� Site Mitigation Well Permit Application