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SAN JOAQUIN Environmental Health Department --COUNTY-- .( SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS 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 San Joaquin County Well Standards. Job Address 16777 Howland Road City/State/Zip Lathrop, CA 95330 Phone 209-858-2511 Cross Street E Louise Avenue APN 19818001 Property Owner* Property: J.R. Simplot; Well Owner: Glenn Springs Holdings Phone Address 16777 Howland Road City/State/Zip Lathrop, CA 95330 C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone 562-427-6899 Address 2726 Walnut Avenue City/State/Zip Signal Hill, CA 90755 Consultant/Sub-Contractor Arcadis US Inc License# 571846 Phone 209-663-8884 Address 400 Capitol Mall, Suite 900 City/State/Zip Sacramento, CA 95814 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING —T X HOLLOW STEM BORING DEPTH 25 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) Li HAMMER/DRIVEN DIA,OF BOREHOLE 8 inches ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0.154 inches TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes Q No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSparoe,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE t0 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/ BORING IDs N. A.1-IR GROUT SPECIFICATIONS Type II neat cement grout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed `^`�T-�` ''� '— +1 Title/Company AI CadIS US Inc Print Name Christine Hughes Date 10/17/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: , f j Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name -orw' u- L��L� L.- FA Address `.�;!�_ t iL,�Vte tl; iL� FA# r' j ( � PR# U FA PE t �� WP Reviewed By `� _—��,�, Work Plan Date r4 ❑C-57 C-57 Authorization for Other to Sign Permit El Worker's Comp ❑WorkBr's qomp Waiver ❑Encroachment Permit ❑Access Agreement Wead Agency Approval 6WMFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# REC 'DPY DATE WELL PERMIT#11 INVOICE# Permit ? �� fir' S $172 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd,com rj,./2GA Ot%�� EHD 29-01 08-01-2024 Site Mitigation Well Permit Application