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- SANJOAQUIN Environmental Health Department <br /> C. `)t-.) f\! T , <br /> SITE MITIGATION brUE L & BORING PERMIT APPUCAT�OVc <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ <br /> Lill , ;:dV, . , utice ht- quire: -; 1 t;1 ".,li Ila:;lac L:f <br /> GAI I_. (204) 953-7997 For INISPFCTIONS <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 Road City/State/Zip Lathrop, CA, 95330 Phone 209-858-2511 <br /> Cross Street E. Louise Avenue APN 198-180-05 <br /> Property Owner' J.R. Simplot Phone <br /> Address 16777 Howland Road �b city)state/zip Lathrop, CA, 95330 �di 1:_�p g3�� <br /> C-57 Contractor Yellow Jacket Drilling Service, LLC Licenseft 1034407 Phone D(, 4 Z — "S -- <br /> Address 9460 Lucas Ranch Road City/State/Zlp Rancho Cucamonga, CA, 91730 32.7Z <br /> Consultant/Sub- ACCadIS <br /> Contractor License# ILIA Phone 916-786-0320 � <br /> Address 101 Creekside Ridge Ct, Suite 200 city/statercip Roseville, CA, 95678 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH —235:tobo detem1Lned ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 16-inch ❑ MULTIPLE CASINOS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOILVAPOR PROBE MUD ROTARY CASING THICKNESS 10-Inch diameter TYPE OF CASING: ❑STEEL ❑PVC ® OTHER SDR17 PVC <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dla: Casing Depth. <br /> ❑ INJECTION(Arsoape.Ozonol ❑ HAND AUGER GROUT BEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE GB PIPE <br /> 2 OTHER 2•troarod ewlnied� ❑ OTHER: GROUT SEAL PUMPED? 2 Yes ❑No (Note:Maximum Freefal)Depth is 30 FI) <br /> � GROUT e U e ' anWELUS01L BORING IDs _ t grout, <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet I <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑3 feel below surface or feet belwi surface if>3 feet <br /> COMMENTS: <br /> where.,v certify that I am authorized to complete this application and that the work will be done In accordance with <br /> _ San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed �/� Title/Company Senior Geologist/ ArcadiS <br /> Print Name Lauren Sipich Date 4/4/2022 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Date . <br /> Destruction Inspection By/Dates: <br /> Facili /81te Information <br /> FA Name FAAddress bqT?­- ffo\4\01 I FA# 100 7,-5- 22 PR# D5L�I4-a) <br /> FA PE 5 WP Reviewed By Work Plan Date <br /> ❑C-57 VL�-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑ Encroachment Peril ccess Agreement ,]bead Agency Approval FR <br /> COMMENTS1t70NDITIONS: fey" !'>.,(/1 If* t(1�CI If <br /> a,,,J _ <br /> j , S r`wµ <br /> Seam <br /> r �� <br /> WP TYPE PE SC I FEE INFb JAMT REPAiTrEd CHECK# I RECV'D BY DATE WELL PERMIT# INVOICEfS <br /> Permit Z�a $152 x - ✓1­0 L) PO Z <br /> 1868 E. Hazeltorr, Aver..ue I Stockton, California 9520,571 i 209 468-3420 1 F 209 404-0"138 1 tAnvtnr.sjc,�ov,orci/ehd <br /> EHO 2e-01 OW29/2022 c /fit r _- ( rr& 0 <br /> 9`( ,d Spx Bile Mltlgetiioon`Well Permit Application <br />