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ECEI r, COPY o.P4`'ly c SAN .,JOAQUIN COUNTY `'� � �.• •.o LOP y; ENVIRONMENTAL HEALTH DEPARTMENT SEP 0 4 2012 SITE MITIGATION t 41.4 • 600 East Main Street, Stockton, CA 95202-3029 UNIT IV �4C)Fp NSP Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: v t lehd WELL & BORING PERMIT APPLICA T/S C�SLTri 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 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 950 Glenn Drive,Suite 125 City Folsom Lic Phone (916)985-2079 Billable Party ARCADIS Address 950 Glenn Drive,Suite 125 City Folsom Zip 95630 Phone (916)985-2079 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) N SOIL BORING IDS Fourty-seven borings total will be advanced ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: \ _❑EXTRACTION:Vapor/Water HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20 ft bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _01 SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes [3No(MAXIMUM FREE FALL DEPTH IS 30 FT) — ❑INJECTION(i.e.Air Soame.Ozone l❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 ft bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING Q No[3 Yes-Casing Dia: Casing Depth: Boring Dia: `1 COMMENTS. 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 C WELL IDs: ❑PRESSURE GROUT TO DEPTH OF Fr BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: [I AUGERS El HOSE [_1 PIPE El MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby cerrify that ha prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation and all cable California laws. Signed Title/Company Project Scientist/ARCADIS WM Print Name Scott Hackman Date 8/30/12 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 617 7 7 &101-040 R 041) MAY WORK PLAN DATED A 1�yI 2y 12- q q APPLICATION ACCEPTED BY o%4 Kl nm DATE ISSUED _ ,I `'t T"'+ ' t'� AREA GROUT INSPECTION BY FINAL INSPECTION BY r 1 t 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# Zgos $ 12 X I O44 �Li -L4-I 2 sR# 6,56-5-'1 19 3 3�S RO# 3500 PR# 2900 C-57 (/ WC (/ WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP