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S A N J O A Q U I N Environmental Health Department i ! COUNTY - ,<rF Greutness grows here. 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 Arcad'Is US Inc License# 571846 Phone 209-663-8884 Address 400 Capitol Mall, Suite 900 City/Statelzip 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 �� X HOLLOW STEM BORING DEPTH 25 feet [21 BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(VaporlWater) 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 [;3 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes [2 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Soarce.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE Q PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes [0 No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs 5.4W-4 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: 1 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 4,C- .L-Q-CL Title/Company Gregg Drilling, LLC Print Na Ryan Lea Date 10/17/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: i n ` �_ It Z� Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name '—t-o r ,1v C;� - FA Address L t 4 cb r lZ L_ I FA# I V -( I PR# 0544 Zt>L FA PE Gl WP Reviewed By Work Plan Date `d ❑ C•57 ❑C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑Workers Comp aiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: (i4i, wt r.t_� WP TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK# I RECV-D BY I DATE I WELL PERMIT# INVOICE# Permit 2qa 3l3 $172 x I I [-I),w -r,)Lljii J(A 34 -" 1 ) ,No 2,1 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com '�tZ ZA° cy✓Y� EHD 29-01 08-01-2024 Site Mitigation Well Permit Application