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SAN J O A Q U I N Environmental Health Department COUNTY Greatness crows mr— SITE MITIGATION WELL 8t: BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE 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 9-1115.3,and the San Joaquin County Well Standards. Job Address 16777 Howland Rd City/State/Zip Lathrop/CA/95330 Phone 209-858-2511 Cross Street APN 19818008 Property Owner" Simplot Phone 209-858-2511 Address 16777 Howland Rd City/State/Zip Lathrop/CA/95330 C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone 925-313-5800 Address 950 Howe Rd City/State/Zip Martinez. CA 94553 Consultant/Sub-Contractor Geosyntec Consultants, Inc License# Phone 916-637-8334 Address 3043 Gold Canal Dr., Ste. 100 City/State/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIPINS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE (EXTRACTION(Vapor/Water) HAMMER/DRIVEN DIA.OF BOREHOLE ((o' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 10 ❑ SOILVAPORPROBE Qv MUD ROTARY CASINGTHICKNESS s TYPE OF CASING: [ISTEEL El PVC CSTd PVC Et OTHER 5 7- lN 65 S Fe- El LJ SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE%IPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED?-1 Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs EW-18B GROUT SPECIFICATIONS N¢A,T- F—111-r DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [-]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with rounty Ordinance Codes and Standards,and all other applicaple California aws.SignedA'Joa �'�• Title/Company rOl Print Name FEW517 e.0 Date Z6' /r9' DEPARTMENT E ONLY Application Accepted By: Date Issued: h6 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name S I S FA Address 110ri vw t,;,,� edl FA# 0 V PR# Fti-,9242- FA PE / O WP Reviewed By Work Plan Date ❑i C-57 ❑C-57 Authorization for Other to Sign Permit Q orkers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement []Lead Agency Approval 1340- COMM ENTS/CONI DITIONS: 340COMMENTS/CONDITIONS: WP TYPE PE p Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit -M 0 Y �13 $152 x 1 , 1S2 l oS-� l'"y 'I`1'i 003 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 L Site Mitigation well Permit Application w P �3 5-2-7, 3 1,%-Z y 1 4'1S to t 0 y$ L 31gl Cl 5'9-oo T0 Z-7X