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ANO UAQ0i11 Environmental Health Department. m 04 SITE MITIGATION V L L�=11L, Q C311INiRING PERMIT -Q`U UUU M NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k4 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 209-853-2511 Cross Street i.ouise AvenueAPM 19&180-05 Propertyowlner' J.R. SIi1lp10 t Phone address 16777 Howland Road yb QoX 27 city/state/zip Lathrop, CA, 95330 5a, C-57 Contractor Yellow Jacket Drilling Service, LLC License#F 1034407 PhoneADZ —0"54 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonga, CA, 91730 302 9 ConsultanPlSub- ArCadls Contractor Licenser/ NA Phone 916-786-0320 Ir Address; 101 Creekside Ridge Ct, Suite 200 city/state/zip Roseville, CA, 95676 COWS`rRUCT10�11fUORF� TO ®E PERFOR{'L7FCD: `Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELL/I3DRIfdG NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH -23s; to be datertnlnod ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OFBOREHOLE 16 -inch ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE MUD ROTARY CASING THICKNESS 10 -inch diameter TYPE OF CASING: ❑ STEEL ❑ PVC ® OTHER SDR17 PVC ❑ SOILBORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION (Air Spago,ozoral ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE [0 PIPE ® OTHER 2-traated gW injection ❑ OTHER: GROUT SEAL PUMPED? Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDs JW/ 0556 ]Ww 06 GROUT SPECIFICATIONS Type IIN sulfate resistant grout. 1111!1:11 r GROUT SPECIFICATIONS TREMIE TYPE TO BE USED C3 AUGERS ❑HOSE [I PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY} D� (,�Jp r ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet belav surface or feet below surface if >3 feet erdry that f am authorized to camplet® this San Joaquin County Ordinance Codes and ICh �llcatian anti that fhe work vyill btr done in accordanc antiards, and all other applicable California laws. Title /Company Senior Geologist/ Arcadis Date 4/4/2022 Application Accepted By: (/ V / Date Issued: Grout Inspection BylDate , �" �t Destruction Inspection By/Dates: FA Name FA Address Q �1�� OVJ 1G�1�a FA# VI� Z � FA PE � WP Reviewed By Work Plan Date ❑ C-57 G57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Aocess Agreement P .Lead Agency Approval FR COMMENTS! NDtT10NS: �WQI'. 5 ��6 FST S CaK p� b,•L,.�Q4 �i �"�' ' , lNP TYPE �P+E SC FEE IN AMT �R. E ITTE CHECK#t RECV'D BY DATE Won WELL �PERMIT// INVOICE#E1'emiii $152 x 'i: �1 L 186iJ �, I`i2zaitorr ,�Vc;-r_iE' I �iocl;�on, Ccii�iot'rtia 95��5 I � 2Q9 �i6�-3=��20 � 5� 209 �.+vd-J'i3 8 1 NA��:�'<Ar.�j�,�ov,�rglahu EHD 29-01 0312912022 � r �,{! Site Mitigation Well Permit Application