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1 , S A N 10 A Q U I N Environmental Health Department — COUNITY - -;4 Greatness grovis Mere. 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 and 19818005 Property Owner* Property: J.R. Simplot; Well Owner: Glenn Springs Holdings Phone Address 16777 Howland Road CitylState/Zip Lathrop, CA 95330 C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone 562-427-6899 Address 2726 Walnut Avenue CitylState/Zip Signal Hill, CA 90755 Consultant/Sub-Contractor Arcad'Is 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 ❑ HOLLOW STEM BORING DEPTH 35 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(VaporMaler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER l0 SOIL BORING —�❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSoarge.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ OTHER [2 OTHER: direct push GROUT SEAL PUMPED? ❑ Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs R N, r l2-B R�B—GROUT SPECIFICATIONS e , DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED backfill 3 soil borings ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs BH-1 B, BH-26, BH-3B ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Type I I neat cement grout ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:] AUGERS ❑ HOSE 10 PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: Borings will be backfilled using a tremle pipe no less than 5 feet from bottom of boring.Borings will be backfilled from total depth to approximately 0.5 feet and capped to match the surrounding surface(e.g,asphalt) 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 C►t 'ti � Title/Company Arcadis US Inc Print Name Christine Hughes Date 10/17/2024 DEPARTMENT USE ONLY Application Accepted By: e�-1 Date Issued: LO� Zd� 7i¢ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name v v OLD— FA Address �� 11�wf/u✓� �� FA# PR# O�Rek v ( FA PE 2 6 S WP Reviewed By Work Plan Date -1�4 ElC-57 ElC-57 Authorization for Other to Sign Permit I—] WorkersComp El Worker's Comp Waiver Encroachment Permit El Access Agreement ❑ Lead Agen Approval ❑ MFR COMMENTS/CONDITIONS: ��jl c ry6,N . ryr - 13. -4i3 WP TYPE PE Sc FEE INFO AMT REMITTED1 CHECK# RE V'D BY DATE WELL PERMIT# INVOICE# Permit 2 3 $172 x - �I 1i [a 1 'ZA 002 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 ( www.sjcehd.com `At 2 EHD 29-01 08-01-2024 Site Mitigation Well Permit Application