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• � f -70CEIVE1LE COPY oR°'�'�`••.c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN*PR 18 2014 LOP abig` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �'•.- 4 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: LTH UNIT IV A�fFOiR ` S 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. /4$/$V-.08 Site Location 16777 Howland Road Cross Street E.Louise Ave City/State Lathrop Zip 95330 APN 198 429'98' Property J.R. Simplot Corp 16777 Howland Road Lathrop 95330Owner Address City/State p Phone (209)858-2511 C-57 Contractor Woodward Drilling Address 550 River Road City/State Rio Vista Lic 710079 Phone(707)374-4300 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 37,01c86 Y '(2(. x733 CONSTRUCTION WORK TO BE PERFORMED: N NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs N WELL IDS PW01-230,PW30-230,PW33-90,PW33-150,and PW33-210 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 5 M MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch 19 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 IN MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 9 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:[I Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 to 245 feet bgs ❑BOLTED TRAFFIC BOX OR 9 STOVE PIPE CONDUCTOR CASING❑p 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 Regulations and all applicable California laws. Signed Title/Company C P^^ Print Name Scott Hackman Date Y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS/�nZ(,� 7'7 7 /¢aw zniyA RJ, L-ra r 424)P WORK PLAN DATED /9(20—'/ /3' Zy r`f APPLICATION ACCEPTED BY J•y0fiKvo� DATE ISSUED �'Z� / AREA GROUT INSPECTION BY FINAL INSPECTION BY 0 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 c REQUEST �P/RQ# ,2*) ( $125x5 Io'T S`l� Lfouwr.<-2 SR# RO# 3500 PR# (2900 C-57 ✓ WC WAIVER /'V W— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT l/ ENCROACHMENT DOC YI EHD 29-01 5/09/12 WELL PERMIT APP