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SAWJOAQUIN Environmental Health Department ---COUNTY— ,i ,..,, Can:,ll nt (1 !)r n•,,; Irt r . SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REKUNDABLE 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 9-1116.3,and the San Joaquin County Well Standards. Job Address _ ___ _ 17151 S. McKinley citylstatetzip Lathrop, CA 95330 phone 209-858-2511 Cross Street S Howland Rd and E Louise Ave APN See attached Parcel Map 19818009 Property Owner' J.R.Simplot Company Phone Address P.O.Box true City/State/Zip Balsa,In 8 707 C-57 Contractor Gregg Drilling License# 1044456 Phone 925-313-5800 Address 950 Howe Road Cltylstatoizip Martlnez CA 94553 ConsultanUSub•Conlractor Wood PLC _License# 697810 Phone 559_-259-2674 Address 1281 E Alluvial Ave, Ste 101 City/slatelzip Fresno, CA 93720 _ CONSTRUCTION WORK TO BE PERFORMED: 'Note: OrfsHe Borings/Wells Require Access Agreements or Encroachment Permits TYPEOFWELI.IDORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 15 feet max ❑BOLTEOTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporAValei) ❑ NAMMERAMNEN DIA.OFSOREHOLE 21nches ❑MULTIPLE CASINGS[I MULTILEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N SOIL BORING —T!5 -121 PUSH POINT(f /CPT) CONDUCTOR CASING ❑Yes ❑No aging Dia: Casing Dia: Casing 0ep1h: ❑ INJECTION(AkSune.One ❑ HANDAUGER GROUTSEALDEPTH TREMIENPE TO BE USED: [I AUGERS [I HOSE ®PIPE ❑ OTHER O OTHER: GROUTSEAL PUMPED? ❑Yes []No (Now Madmum Freelal Depth is 30 Fit WELL/SOIL BORING Me 6-1Thrcugh B-B,SW4,SW-2,SW-3,SS-1 GROUT SPECIFICATIONS portland cement 83-2,BG.1 andone bodieg to delermina GW depth - - DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(OHECI(ALL THAT APPLY! #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER OI_Inches io depth Of_feet WELL IDs ❑PRESSUREGROUT To depth of feet belowsudace GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface THEME TYPE TO BE UBED ❑AUGERS-❑HOSE ❑PIPE ❑MUSHROOM CAP 3(eel bebwsudaceor . feel balmy audaceif>31eel COMMENTS; I hereby certify that I am authorized to complete this application and that the work will be done In accerdanco with Sand agi in Can Ordinance Codes and Standards,and all other applicable California laws. Signed_ rf Title/Company Office Manager, Gregg Drilling, LLC Print Name Mary V en Dale 12/30/2020 - DEPARTMENT USE ONLY Application Accepted By; Jeffre Wong Date Issued: 3/18/2021 . . Grout Inspection By/Dales: rA r�--�1 I.7 -r, / -, ,c'] y Destruction Inspection By10 s: / �—�� acllil /Silo Infonnollun � FA Name JR SIMPLOT FA Address 16777 HOWLAND FAN FA0026428 I PRO 1 PR0546589 1 FA PE 2965 VIP Reviewed By J W Work Plan Dais 11/23/2020 57 ❑C37Aulhadul5Dn(%Olhorlos'gn Pamll ❑WakeesComp ❑WorkeescempWaiser ❑iiwaishrenlPamil ❑Acc wAgreemenl ❑Lead Agency Approval R COMMENTSICONDITIONS: Submit report of analysis/finding to EHD per SJC Well Standards 13.7.2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE I WELL PERMIT# INVOICE# Permit 2905 313 $152X 3 456 JW 32 WP0041831 1 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464.0138 1 www.sjcehd.com ERG 29410"1.17 She Millgallun Wel Parnell Apperauan I Confirmation Number: 121404993 SR0083431