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- INAL 1111�- =CE Y°'A°�"'" SAN JOAQUIN COUNTY :�.Ft.co ENVIRONMENTAL HEALTH DEPARTMEN*PR 18 2014 LOP N: < •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ORa`P• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:OWWWWLTH UNIT IV WELL & BORING PERMIT APPLICATION 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. 118,180-08 Site Location 16777 Howland Road Cross Street E.Louise Ave City/State Lathrop Zip 95330 APN 198?28 80• Property J.R. Simplot Corp 16777 Howland Road Lathrop 95330 209 858-2511 Owner Address City/State Zip Phone ( ) C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic 710079 Phone(707)374-4300 Consultant/Sub Cntr ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone (916)786-0320 Billable Party ARCADIS / Address 1101 Creekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X 3 7.�oBG Y —(-Z(. �7 33 CONSTRUCTION WORK TO BE PERFORMED: ❑W NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑■ WELL IDS PW01-230,PW30-230,PW33-90,PW33-150,and PW33-210 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 5 N MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch E MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL E PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑p MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:N Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 to 245 feet bgs ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Offsite wells are included in the attached work plan.A separate permit will be applied for when access agreements have been procured. 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 IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑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 all applicable California laws. Signed Title/Company C'p-1 Print Name Scott Hackman Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS &A 7'7 7 1100 Z VjVA Rj. 44 r 44eO A � WORK PLAN DATED W l3 2o fq APPLICATION ACCEPTED BY J•H0fiKaK'l DAT ARgA16 9 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE 104P PCO PW COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE !' REQUEST p LP'R# 2J0 ( $ 125xS tO'T SL13 61ouwr6,� �{Ig'l SR# 4 7 1 �C(U3 37� RO# 3500 PR# 2900 C-57 ✓ WC WAIVER FXT C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC M)q EHD 29-01 5/09/12 WELL PERMIT APP