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SAN JOAQUIN COUNTY ENv.RONMENTAL HEALTH DEPARTI\,.c_NT Z7TIE_MItIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT .IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd WELL & BORING PERMIT APPLICATION MAR 2013 AW FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fir .•.,, Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made ritFaqTplia Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ,jp�jvq. # Site Location 16777 Howland Road Cross Street E.Louise Ave. City/State Lathrop/CA Zip 95330 APN 198-140-04 Property Owner J.R.Simplot Corp. Address 16777 Howland Road — City/State Lathrop/CA Zip 95330 Phone (209)858-2511 C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez/CA Lic 485165 Phone (925)313-5800 Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Drive,Ste 330 City/State Roseville/CA Lic Phone (916)786-0320 Billable Party ARCADIS Address 1410 Rocky Ridge Drive,Ste 330 City/State Roseville/CA Zip 95661 Phone (916)786-0320 GIS Coordinates:X Y_ CONSTRUCTION WORK TO BE PERFORMED: FOR NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 SOIL BORING IDs N WELL IDs PW30(nested 30'and 80'),PW30(nested 130'and 180),PW31-30,PW31-80,PW31-130,PW31-180,PW32(nested 130'and 180') El OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _N MONITORING N HOLLOW STEM DIA.OF BOREHOLE 10 inch M MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: —0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS Sch 80 TYPE OF CASING: 0 STEEL IN PVC 0 OTHER _[3 SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL see table TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 9 PIPE —0 SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED: 9 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION(i.e.,air Soarge,Ozone)0 HAND AUGER GROUT SPECIFICATIONS neat cement —0 OTHER: 0 OTHER: APPROX.BORING DEPTH see table 9 BOLTED TRAFFIC BOX OR 9 STOVE PIPE CONDUCTOR CASING N No E]Yes:Casing Dia:_Casing Depth:_ Boring Dia:_ COMMENTS:Monitoring wells will be installed in clusters.Above grade or at grade completion will be determined based on traffic in the proposed area. 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: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS [I EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:[3 AUGERS 0 HOSE F1 PIPE El 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 Regulatiors,an all applicable California laws. SigneTitle/Company CiCPMI D7-. s d_�� Print Name 5X-.1-'f Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Lo 7'?'? How/_/4X) WORK PLAN DATED ig A)p(jq IZ-A 20, 3 psgft=��M�Wwwvb APPLICATION ACCEPTED BY DATE I W&AW AREA GROUT INSPECTION BY FINAL INSPECT' m_-w^usPwP0ATE DESTRUCTION INSPECTION BY DATE 77 COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 2�0 $ 125, 10 50 C., 38"z a,KR-k -21-13 SR# RO# _25- 37S (3500) PR# (2900) C-57 t1' WC t,' WAIVER W4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-01 5/0q/12 WELL PERMIT APP