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S A N J O A Q U I N Environmental Health Department C o u r,l-i� 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 5855 West Lake Cfark Lane City/State/Zip Tracy,CA 95304 Phone (408)599-4030 Cross Street APN 252-150-150-000 Property Owner' Ernest Pombo Jr. Phone Address PO Box 269 City/State/Zip Tracy,CA 95378 C-57Contractor CalWater Drilling License# 434218 Phone (209)667-7932 Address 300S.Kilroy Road City/State/Zip Turlock,CA95380 ConsultantlSub-Contractor Geosyntec consultants License# 766859 Phone (510)285-2682 Address 1111 Broadway,6Ih Floor City/State/Zip Oakland,CA 94607 CONSTRUCTION WORK TO BE PERFORMED:"Note: Off site Borings[Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ 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: ElINJECTION(Av Spmge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ElPIPE ❑ 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 4 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS MW-9,MW-10,MW-11,MW-12(see attached Work Plan) 0 PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland cement mixed with 3-5/bentonite gel ❑EXPLOSIVES Front to feet below surface TREMIE TYPE TO BE USED ❑AUGERS [-]HOSE 0 PIPE ®MUSHROOM CAP 0 3 feel 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 S_a oa in County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company CalWater Drilling Company, Inc. Print Name Matt Hennings Date 5/15/2026 I DEPARTMENT USE ONLY /t / Application Accepted By: I ` Date Issued: —G t Grout Inspection By/Dates: Destruction Inspection By/Dates: J' Facilil /Site Information FA Name [��l�1 � .i r FA Address Lb �U FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit Q Worker's Comp ❑Workers Comp keiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE t WELL PERMIT# INVOICE# Permit $179 x �� 7 ( '! l'(. �VI �L 01 I Z G 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29 01 07-01-2025 Site Mitigation Well Permit Application