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S A N J 0 A 0 U I N Environmental Health Department <br /> COUNTY <br /> IC, Greotness crows h <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 16777 Howland Rd City/state/Zip Lathrop/CA/95330 Phone 209-858-2511 <br /> Cross Street APN 19818008 <br /> Property Owner* Simplot Phone 209-858-2511 <br /> Address 16777 Howland Rd City/State/Zip Lathrop/CA/95330 <br /> C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone 925-313-5800 <br /> Address 950 Howe Rd City/State/Zip Martinez, CA 94553 <br /> ConsultanUSub-Contractor Geosyntec Consultants, Inc License# Phone 916-637-8334 <br /> Address 3043 Gold Canal Dr., Ste. 100 City/State/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL)SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs EW-18B N PRESSURE GROUT To depth of 185 feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGER HOE x PIPE ®MUSHROOM CAP x❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify"t I am authorized to complete this application and that the work will be done in accordance with <br /> n o, uin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed "` Title/Company o� /,?n <br /> Print Name Date Z Z 6 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# 00 LS-1PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑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 <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 , Site Mitigation Well Permit Application <br /> VVf TM03 SlZ1 tSL �C j 4s� VOX �'' 3L4119 s�a�v�-?8 <br />