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7 SAN ) 0 A Q u I Environmer„-I Health Department Greatness grows here 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 Approximately 17999 McKinley Road City/State/Zip Lathrop/CA/95330 Phone 209-858-3365 Cross Street Vierra Road APN 19815001 Property Owner* Simplot Phone 209-858-3365 Address 16777 Howland Road City/State/Zip Lathrop/CA/95330 C-57 Contractor Yellow Jacket Drilling Service,LLC License# 1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonga CA 91730 Consultant/Sub-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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I29 MONITORING 1 ❑ HOLLOW STEM BORING DEPTH 280 ft bgs ❑BOLTED TRAFFIC BOX M STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA OF BOREHOLE 8” ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA [I SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: E]STEEL❑ PVC❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ©PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs PW-2-270 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: One monitoring well will be installed to a maximum depth of 300 ft logs. See attached table with well specifications. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San JQa it Ordinance Codes and Standards,and all other applicable California laws. Signed G�� -_�� Title/Company Senior Geologist/Geosyntec Consultants, Inc. Print Name Nicole Gotberg Date November 15, 2018 DEPARTMENT USE ONLY Application Accepted By 1 Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information 1�1 D FA Name FA Address #i; V'loJL4Mt� F-el FA# �)OZy'1 PR# -)S-143 Sok FA PE V WP Reviewed By L— /'X Work Plan Date ( I ( � 1 y V >; e ❑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 1,. , pWELL PERMIT# INVOICE# Permit >it t 3 I $152 x t i 1 55Z W�i io Z �} lK 1 out a 9 A 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0&01-17 Site Miti ation Well Permit Application �,,►P X103 523 ts�i( 3 kSU 1140 1, SfLocI386