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QUlgr SA N J OAQ U I N Environmental Health Department COUNTY iF6 Greatness grows 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 12749 Thorton Rd. City/State/Zip Lodi. CA. 95242 Phone N/A Cross Street N Cord Rd. APN 5513016 Property Owner* City of Lodi White Slough Water Pollution Control Facility Phone (209)333-6749 Address 12751 N.Thornton Road 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 Clav Sorensen/West Yost Associates License# CHG#1108 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 E3 EXTRACTION(Vapor/Water) ❑ 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 0 SOIL BORING ❑c PUSH POINT(GP/CPT) CONDUCTOR CASING ❑o Yes ❑No Boring Dig, Casing Dia: Casing Depth, ❑ INJECTION(AirSparae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? U Yes 9 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 0 OVER-BORE DIAMETER of 825 inches to depth of 20 feet WELL IDS WSM-2 ❑PRESSURE GROUT To depth of N/A feet below surface GROUT SPECIFICATIONS 3-5%Bentonite clay,B-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 0 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or N/A 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 Hvdrocleoloclist/West Yost Print Na a Clay Sorensen Date 10/22/2025 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $179 x 1868 E. Hazelton Avenue l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 Site Mitigation Well Permit Application