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San Joaquin County <br /> za Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd LINI IV <br /> A��FOR� Well Permit Application ' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JVpor'�ppr�CLii14 COONT Y <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicationrr ��i t� UtrT <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health nanart <br /> 1677 Howland Road 95330 Assessors <br /> Louise Ave Lathrop 19t--,80-05 <br /> WELL Location Cross Street_ _City Zip Parcel# <br /> PROPERTY J.R.Simplot Company 16777 Howland Road Lathrop 95330 <br /> Owner _Address City Zip_ Ghone# <br /> C-57 ContractcrNeil O.Anderson&Assoc /,ddress_902 Industrial Way _City Lodi Zip 95240 i.r;4 669004 Phone#209-367-3701 <br /> Consultant/Sub Cntr Address,902 Industrial Way City Lodi Li(;ft_PG7834 _Phone#209-367-3701 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> - NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") )tDESTRUCTION (choose typo <br /> p SOIL BORING# ;6 OVER-BORE. DIAMETER_10 inch <br /> ELL#-- a PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS:_ Destruction of LP-5 !?1At'��(��_� ��. i2,�\ to r�� �•f, ��.� a , Lig �(�T e• r ^�r �L +^��- �, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> g MONITORING R HOLLOW STEM DIA.OF BOREHOLE—8 inchp MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA:2_jnch_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS sch 40 TYPE OF CASING: O STEEL J&PVC O OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 8 feet TREMIE TYPE TO BE USED: J AUGERS p HOSE <br /> 0 AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )Q Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS gal H2O, per 94 lbs cement, plus 3 lbs bentonite powder <br /> p OTHER: fl OTHER APPROX.BORING DEPTH 25 feet 0 BOLTED TRAFFIC BOX or H STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certifdces, <br /> have p pared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinaRule nd Regulations, and all applicable California State Laws. <br /> Signed x Title/Company_Senior Geologist-Neil O.Anderson&Assoc <br /> Print Name Ja Robinson Date December 4, 2006 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: PC4 r <br /> WORK PLAN DATED: ' <br /> Application Accepted By Date Issued /7-/5-/o 6 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By s.�" Date 2_ ( v <br /> COMMENTS ICON DITION — PAjj,jXd tV- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> c�`�ol 85 O° 8S°� Z1e69 1414 SR#Lm <br /> 1073 <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />