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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 and 19818005 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 ConsultantlSub-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 ❑ HOLLOW STEM BORING DEPTH 35 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ 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 I;3 SOIL BORING —�❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(lir Soarae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER [a OTHER: direct push GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs $H 1 R, R H_2 R, BH2 R_GROUT SPECIFICATIONS 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-2B, 131-1-36 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Type II neat cement grout ❑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: Borings will be backfilled using a tremie 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 011il 'Utz _ff_1� Title/Company Arcadis US Inc Print Name Christine Hughes Date 10/17/2024 DEPARTMENT USE ONLY I Application Accepted By: )A, Date Issued: Grout Inspection By/Dates: r, Destruction Inspection By/Dates: Z�1 Facili /Site Information FA Name f VWa-,r- pL'L- FA Address j ,.v�/;y(,/ j7,� FA# ' --��Z PR# FA PE 2 q 6 -I- WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Camp ❑Workers Comp Waiver EfEncroachmentPermit ❑Access Agreement ❑Lead Agen Approval ❑MFR COMMENTS/CONDITIONS: �( ` '�V ,� �/� 7SL WGvt OYL 13. --IJ WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE V'D BY DATE WELL /PERMIT# INVOICE# Permit 2�b 5� 3( 3 $172 x 516 Lu 5� � 2� 00)M 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com 711( EHD 29-01 08-01-2024 Site Mitigation Well Permit Application