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NECEIV `...� �o•.�;F,co SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN*PR 1 8 2014 a LOP a` `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �' .- a'p Telephone: (209) 468-3147 Fax:(209) 468-3433 Web: LTH FOUNIT IV 4�rR ` 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. i48 /$0-C58 Site Location 16777 Howland Road Cross Street E.Louise Ave City/State Lathrop Zip 95330 APN 198 429-99' 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(7C7)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,ao8G Y CONSTRUCTION WORK TO BE PERFORMED: ❑m NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs H WELL IDS PW01-230,PW30-230,PW33-90,PW33-150,and PW33-210 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 5 H MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12-inch 9 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch-80 TYPE OF CASING: ❑STEEL ❑. PVC ❑ OTHER _❑SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL various TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE N PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 105 to 245 feet bgs ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE CONDUCTOR CASING O 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 ALLTHAT APPLY) #OF W ELLS)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 Print Name Scott Hackman Date Lf DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS/�/�,/ ?& 7?'? 110 w C19NA Rj" /.4 /� CC��J' r�P WORK PLAN DATED mI1J. 26 �'t/ APPLICATION ACCEPTED BY ill 0&K(40� DATE ISSUED 4-ZZ-"1 AREA GROUT INSPECTION BY FINAL INSPECTION BY 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# 2ic co $ 125xS (OS Sy�j Qourvre-� SR# Gq�B �TV3 37� RO# (3500) PR# (2900) C-57 ✓ WC ✓ WAIVER l'yi9- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC AI)q EHD 29-01 5/09/12 WELL PERMIT APP