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' - o" �� S A N sJ0 A Q U I N Environmental Health Department COU NTY i �q,4LI Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 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 209-858-2511 Cross street E. Louise Avenue APN 198-180-05 Property Owner* J.R. Simplot Phone Address 16777 Howland Road City/State/Zip Lathrop, CA, 95330 C-57 Contractor Cascade Drilling License# 1058336 Phone 916-638-1168 Address 3000 Duluth Street City/State/Zip West Sacramento,CA,95691 Consultant/Sub-Contractor Arcadis US Inc License# NA Phone 916-786-3020 Address 101 Creekside Ridge Ct, Suite 200 City/State/Zip Roseville, CA, 95678 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Swroe.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYt #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs IW-2 5?PRESSURE GROUT To depth of 275 feet below surface GROUT SPECIFICATIONS Type IIN Sulfate resistant grout ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE R PIPE MUSHROOM CAP 2 3 feet below surface or feet below surface if>3 feet COMMENTS: This well mlWpeeClleileE,If,ere is roweeClment 1111ing pre wen lmm blel Eepm(510)to epproxlmatey LlS teat Dalow ground 6urlece Meny enercphroremova Mie seaimmt Ne Cevelopmenl veru uneucceseNl,wn mlr,k let here wasa slgnMunt creek lnlM,syng at-1]5 teat opa. I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Senior Geologist/Arcadis Print Name Lauren Sipich Date 3/16/2022 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilf /Site Information FA Name FA AddressD FA# Cl C, 2!j PR# 0 5 ' FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: .� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'DBY DATE WELL PERMIT# INVOICE# Permit 2 6 13$152 x 2 ,JK :3 ) 1 2 u :5g �vs5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-01 8 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application