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SAN .10AQUIN COUNTY J iECEIVED :s ENVIRONMENTAL HEALTH DEPARTMENT LOP SEP 16 20 600 East Main Street, Stockton, CA 95202-3029 ITE MITIGATION Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: .s' ov.oLNVIROMr lehd. HEALTH IV WELL & BORING PERMIT APPLICATIOMRMIT/SERVICES 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 Rd Cross Street E. Louise Ave City Lathrop Zip 95330 APN 19814004 Property 16777 Howland Rd. Lathrop (209)858-2511 Owner J.R.Simplot Address City p Zip 95330 Phone C-57 Contractor Cascade Drilling,L.P. Address 3632 Omec Circle City Rancho Cordova Lic 938110 Phone (916)638-1169 Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Dr Suite 330 City Roseville Lic 571846 Phone (916)786-0320 Billable Party ARCADIS Address1410 Rocky Ridge Dr Suite 330 City Roseville Zip 95661 Phone (916)786-0320 GIS Coordinates:X 37.80861 Y -121.278 CONSTRUCTION WORK TO BE PERFORMED: 29 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs EW-9/PW27-40/PW28-40/PW2940 ®OTHER IDs PW26-086/PW26-1 TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -3 ®MONITORING IN HOLLOW STEM DIA.OF BOREHOL 2„/8„/8„/8„❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 6„/7/212„ 1 IN EXTRACTION:Vapor ater ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ®1STEEL X�IPVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5ft TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:91 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJE TION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement grout ®OTHERWell Cutoff/extensiorb OTHER: APPROX.BORING DEPTH 40ft ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE PW26-086/PW26-154/ CONDUCTOR CASING❑No CI Yes:Casing Dia: Casing Depth: Boring Dia: fV1 COMMENTS: Well cutoff/extension scope of work is attached = AA-p OA-i mtt J24 [A p -'- qp 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 10s: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:ElAUGERS E]HOSE ElPIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio s,and all ap Ii ble California Laws. Signe Title/Company Pro,ec t Se stn t, I /42 C 449:,5 u,$._ :7;;e . Print Name Stof f• Ho-etzmAg Date 9//.s�/1 ' /� ^� DEPARTMENT USE ONLY,a`- w SITE MAP IN UNIT IV FILE ITE A DRESS l�, l'7/ �t X , &J • LAt�""'12 WORK PLAN DATED �S )�atl t APPLICATION ACCEPTED B L3v DATE ISSUED 9 G AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 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# ,Po7 d 2— $125 x to 7�0" L8 — `Zo r SR# 063 51 KV IF (3500) C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC