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REG t,1%JrW oP4`'ity c SAN JOA UIN COUNTYR"y goNVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION RONMENTALh1 ast Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV 68-3454 Fax: (209) 468-3433 Web:www.smgov.org/ehd 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 Lathrop Zip 95330 APN 198-140-04 Property Owner J.R. Simplot Corp. Address 16777 Howland Road City Lathrop Zip 95330 Phone (209)858-2511 C-57 Contractor Cascade Drilling Address 3632 Omec Circle City Rancho Cordova Lic 938110 Phone(916)638-1169 Consultant/Sub Cntr ARCADIS Address 1410 Rocky Ridge Drive,Suite 330 City Roseville Lic Phone (916)786-0320 Billable Party ARCADIS Address 1410 Rocky Ridge Drive,Suite 330 City Roseville Zip 95661 Phone (916)786-0320 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs EW-10. EW-11. EW-12A. EW-1213. EW-13. EW-14A. EW-146. EW-15A. EW-1513. EW-17 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS 91 MULTI-LEVEL WELL CASING DIA: 6.. 10(9 EXTRACTION:Vapor Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 80 TYPE OF CASING: R STEEL ®PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL see table TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat Cement Grout ❑OTHER: I3 OTHER: Sonic APPROX.BORING DEPTH see table ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Wells EW-12A, EW-14A,and EW-15A are to be installed with multiple screened intervals, see attached table for additonal details 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 Regulat'io�n-si,and a applicable California Laws. Signed .l�– - Title/Company C P— ' R c,q DrS Print Name Sce,tt- I4actcw-1 Date 1(- i 7-rZ ^� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 147/ 7 / ow l�N/Z _, tgr�QvF WORK PLAN DATED �r APPLICATION ACCEPTED BY ^ y0 /J�Kct ryl DATE ICB ' )MED AREA �G GROUT INSPECTION BY _ FINAL INSPECTION BY 51 DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# a 901 $125 x /U /z5 6 G/SSS 2 TQ -12 SR# Ro# 3 3500 PR# 2900 C-57 WC [/ WAIVER 424- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT «_ENCROACHMENT DOC Wy