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s � SAN JOAQUIN COUNTY I G1 �9 �1 ENVIRONMENTAL HEALTH DEPARTMENT LOP .Z SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV )FOR�•p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siUov.orcl/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards of the San Joaquin County Environmental Health Department. Site Location 16777 Howland Road Cross Street E.Louise Ave City/State Lathrop Zip 95330 APN 198-120-09 Property J.R. Simplot Corp 16777 Howland Road Lathrop 95330 209 858-2511 Owner Address City/State p Zip Phone ) C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez,CA Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑m NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs 0 WELL IDs PW33-85,PW33-125 and PW33-175 ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6.5-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL R PVC ❑ OTHER _❑SOIL VAPOR PROBE N MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑O Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 90.130,and 180 feet bgs ❑BOLTED TRAFFIC BOX OR N STOVE PIPE CONDUCTOR CASING N No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Offsite wells are included in the attached work plan.A separate permit will be applied for when access agreements have been procured. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT To DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations nnri all applicable California laws. Signed ly S.X Title/Company Vice President/ARCADIS Print Name Liz Sewell Date 6/13/2014 / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �-03RJfb WORK PLAN DATED APPLICATION ACCEPTED BY ,� - �� DiC(iL�1 DATE 1 .,e. REA �o GROUT INSPECTION BY FINAL INSPECTION BY ATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST LPR# U $125x S�P �� LtQU&76(L L-17-t SR# (R3 00) PR# (2900) C-57 V, WC l✓ WAIVER C-571 ETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC_/ _ EHD 29-01 5/09/12 WELL PERMIT APP