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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N A X11 : � ,•� 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siSlov.org/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXP RE t YEAR FROM DATE I ED 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 Lathrop Zip 95330 APN 19814004 Property J.R.Simplot 16777 Howland Road Lathrop 95330 209 858-2511 OwnerAddress City^ Zip Phone ) _ C-57 Contractor PeneCore Drilling Address 1238 Alice Street,Suite A City Woodland Lic 906899 Phone (530)661-3600 Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Drive,Suite 330 City Roseville Lic 41111111111111111111 Phone (916)786-0320 Billable Party ARCADIS — Address 1410 Rocky Ridge Drive,Suite 330 City Roseville Zip 95661 Phone (916)786-0320 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) N SOIL BORING IDs IlST_1 TFA-1 FKC.V-1 EXCV 2 P'^rg-! cn-I an, cR_2 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑ EXTRACTION:Vapor/Water E HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE Cl MUD ROTARY DEPTH OF GROUT SEAL 50 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE W PIPE J SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: N Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑ INJECTION(i.e.Air Soaroe.Czone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER. APPROX.BORING DEPTH 6-20 feet, 1-50 feet I]BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #OF WELLS)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 C1 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,and Il applicable California Laws. � 3 , " --------Title/Com any ct Sc;e'br c " SSigned --------- Print Name Se v�(-- Hzteie s' e) Date 2-6- :fid DEPARTMENT USE O�Y- SITE MAP IN UNIT IV FILE SIT AT WORK PLAN DATED RESS ( �'i 7��7 -—y-- �k C L//Z- f APPLICATION ACCEPTED BY _ �_.n___ DATE ISSUED _AREA GROUT INSPECTION BY �� E' FINAL INSPECTION BY � � DATE �.-- (2. 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 PR# Il y x i I ZS Y l�J�= /o /Zi SR# 4Pq 3 $125s� CYLOZ � 7S S1� Roo -- - PR# 2900) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _