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SAN .JOA FILE Q UIN COUNTY COPY /Q•�t.co ENVIRONMENTAL HEALTH DEPARTMENT LOP y: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • - �'P Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orq/ehd 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. Site Location 16777 Howland Road Cross Street E.Louise Ave City/State Lathrop,CA Zip 95330 APN 198-140-04 Property J.R. Simplot Owner p Address 16777 Howland Road City/State Lathrop,CA Zip 95330 Phone 209-858-2511 C-57 Contractor Cascade Drilling Address 3632 Omec Circle City/State R111h,C*1011,CA Lic 938110 Phone 916-638-1169 Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Drive,Suite 330 City/State Roseville,CA Lic Phone 916-786-0320 Billable Party ARCADIS Address 1410 Rocky Ridge Drive,Suite 330 City/State Roseville,CA Zip95661 Phone 916-786-0320 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: M NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑O WELL IDs (-0 - ►'R [ ❑OTHER IDs - TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 6-inch _®EXTRACTION:Vapor/ ater ❑HAMMER/DRIVEN CASING THICKNESS Sch 80 TYPE OF CASING: ❑STEEL It PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 164-feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE O PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 205-feet M BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑O No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 1 #OF WELL(S)TO BE DESTROYED M� OVER-BORE DIAMETER OF 1:INCHES TO DEPTH OF I FT WELL IDs: EW-12B ❑O PRESSURE GROUT TO DEPTH OF ATf9- C5" FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE FE 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 Regulation ,and all applicable California laws. Signed Title/Company CIM (-2 c Ab-T-s Print Name s c F /{-e le to Date Z-2 Z•t 3 �.' �^+ r� ,. / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �G 77/ ffndz✓4A-4� 2y FFRg WORK PLAN DATED c JAS RTIT O I �V APPLICATION ACCEPTED BY 0,)f 64/ DATE ISSU DPti :�t�a»IAR EA, _ GROUT INSPECTION BY INAL INSPECTION BY 4 % � �3'.IE1lJ pct,• DESTRUCTION INSPECTION BY DATE -22'/ ~� COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ZC, 0 / $ 125 X �i �1(a 17 7 3-y-►3 SR# 66-1!77Q 0 Z I Z5X (50o b�N9 ? PR# 2 1C 4 3 J ? 5 2908 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP