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QUlgr SQ N 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 15011 N Davis Rd City/State/Zip Lodi, CA, 95242 Phone N/A Cross Street STATE ROUTE 12 APN N/A Property Owner* San Joaauin County(well on county Droperty) Phone N/A Address N/A(Encroachment permit application submitted) City/State/Zip N/A C-57 Contractor Confluence Technical Services License# 1035255 Phone (916)760-7641 Address 6821 8th St. City/State/Zip Rio Linda, CA 95673 Consultant/Sub-Contractor Clav Sorensen (West Yost) License# PG#9605/CHG#1108 Phone 831-706-5135 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 © MONITORING �❑✓ HOLLOW STEM BORING DEPTH 60 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE E3 EXTRACTION(Vapor/Water) E3 HAMMER/DRIVEN DIA.OF BOREHOLE 8 jn [3 MULTIPLE CASINGS E3 MULTI-LEVEL WELL CASING DIA N/A ❑ SOIL VAPOR PROBE [IMUD ROTARY CASING THICKNESS 2 jn TYPE OF CASING: ❑STEEL ❑� PVC ❑ OTHER N/A 0 SOIL BORING 13 PUSH POINT(GP/CPT) CONDUCTOR CASING ®Yes 0 No Boring Dia, Casing Dia: Casing Depth, N/A ❑ INJECTION(AirSaarae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 28 ft TREMIE TYPE TO BE USED: ❑� AUGERS ❑HOSE ❑� PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes El No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement with 5% Bentonite DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE []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 11,14Z Title/Company Senior Hydroaeoloaist/West Yost Print Na ay Sorensen Date11/14/2025 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 I 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