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RECEIVED 4 W I SAN JOAQUIN Environmental HealVeff%Went 3 WiIIII& CJUNTY CawENVIRONNIENTAL HEALTH Greatness grows here -,_ 1)1"PARTi1IENT SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 16777 Howland Road City/State/Zip Lathrop/CA/95330 Phone 209-858-2511 Cross Street APN 19818008 Property Owner* Simplot Phone 209-858-2511 Address 16777 Howland Road City/State/Zip Lathrop/CA/95330 C-57 Contractor Gregg Drilling,Inc. License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez,CA 94553 Cons ultarlub-Contractor Geosyntec Consultants, Inc. License# Phone 916-637-8334 Address 3043 Gold Canal Dr., Ste. 100 City/State/Zip Rancho Cordova,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 95/185/270 ft bgs❑BOLTED TRAFFIC BOX ❑STOVE PIPE ® EXTRACTION(Vapor/Water) 3 ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 16" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA k O" ❑ SOIL VAPOR PROBE IBI MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth _ ❑ INJECTION(Air Soaae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? EI Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs EW-18A.EW-18B,and EW-19 GROUT SPECIFICATIONS Type II-V DESTRUCTION WORK TO BE PERFORMED: 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: Three groundwater extraction wells will be installed to a maximum depth of 270 ft bgs.See attached table with well specifications. I hereby certify that I horized to complete this application and that the work will be done in accordance with S aqt Cpunty Ordinance Codes and Standards,and all other applicable California laws. Signed' o �� Title/Company Senior Geologist/Geosyntec Consultants, Inc. Print Name Nicole Gotberg Date December 4,2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name S �w. ��— FA Address �, LJ � FA# 1 PR# �135 FA PE 1 C1 1'r', WP Reviewed By +T�w Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval [2'IGFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO JAMT REMITTED I CHEC,K.j#� RECV'D BY DATE y WELL PERMIT# INVOICE# Permit �,� �I� >*$152x 3 4 : I'.! 1 L, 2— 7.v IJ b,.)ft()3' lZ 1868 E. Hazelton Avenue I Stockton. California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application w(' W3 31 � �c5ZX3 �-'� 5I"d--,ri W0