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WELL PERMIT APPLICATION ARM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) V�� <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 = <br /> (209) 468-3449 MAY 1 <br /> ZUUi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> WELL Location_ 16777 Howland Road Cross street Louise Ave.Cih, Lathrop CA zip 95330 Assessor's <br /> Parcel# i98— 160-09 <br /> PROPERTYOwner J.R. Simplot Companygddress16777 Howland Rd. city Lathrop CAzip95330 Phone#209/858-2511 <br /> Spectrum <br /> C-57Contractor Exploration, Inc.Address 2365 Wigwam Dr. cityStocktonzir95205 Lic#512-268Phone#209/465-8712 <br /> Geomatrix 2444 Main St. <br /> Consultant/IXYLEMLAMr Consultants, IncAddress Kni re 215 CityFresno Lic# Phone# 559/264-2535 <br /> GIS Coordinates:X Y Township 1 S Range 6 E Section 35, 36 <br /> WORK TO BE PERFORMED: <br /> YA NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> ff WELL# 1 0 PRESSURE GROUT <br /> Other: Hollow—Stem Auger Grout Specifications: Cement Bentonite Grout <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING WOLLOW STEM DIA.OF BOREHOLE 8—inch MULTIPLE CASINGS?0 YES )NNO WELL CASING DIA:2—inch <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: 0 STEEL {PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 feet TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes ::No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Neat <br /> 0 OTHER: []OTHER APPROX.BORING DEPTH 25 feet 9BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? No (if YES,list specifications here):__ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby cert"it I ha e d this application and that the work will be done in accordance with San Joaquin <br /> County Or n s, s and egulations, and all applicable California State Laws.. <br /> Signed x C�Y� Title/Companyol ���d <br /> Print Name /�>� DSS Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED:I ? _�D 01 cy�Z `� �'� [!1 ry r' 04. O <br /> Application Accepted By L- ktl tp Date Issued�ZID/ Area(-0/2 Lt/aCfil <br /> Grout Inspection By Date Final Inspection By Date__ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: vvw <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �7' 8S lac zo 00Z (� 0 � <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />