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SAN OAQUIN COUNTY FILE �. ..� .oG JCOPY ENVIRONMENTAL HEALTH DEPARTMENT LOP �. SITE MITIGATION '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 • c N'P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sipov.orq/ehd UNIT IV A�rFOR ` 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 Zip 95330 APN 198-120-09 Property J.R. Simplot Corp 16777 Howland Road Lathrop 95330 209 Owner Address City/State p Zip Phone ( )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 101 Creekside Ridge Court,Suite 200 City/State Roseville Lic Phone(916)786-0320 Billable Party ARCADIS Address 101 Creekside Ridge Court,Suite 200 City/State Roseville Zip 95678 Phone (916)786-0320 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: 0 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑0 WELL IDs PW33-85,PW33-125 and PW33-175 ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 3 0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6.5-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL E PVC ❑ OTHER _❑SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑p PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:V Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarce.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 90,130,and 180 feet bgs ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING I]No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Offsite wells are included in the attached work plan.A separate permit will be applied for when access agreements have been procured. 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 Regulation- anri ail applicable California laws. Signed d S` Title/Company Vice President/ARCADIS Print Name Liz Sewell Date 6/13/2014 / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS jlt 7�� /➢w413 1-V13/V,b WORK PLAN DATED / / 4./ APPLICATION ACCEPTED BY ,� _ ( � �(iL/(�� DAT O AREA �P GROUT INSPECTION BY FINAL INSPECTION BY U 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 �i REQUEST^'QPIR# $125 x SR# 2�0 2 3 RO# J (3500) PR# (2900) C-57 WC t/ WAIVER— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOCS14 EHD 29-01 5/09/12 WELL PERMIT APP PARrf��RF/°LAc�F��Q S2c)C�(n9�18S`