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WELL PERMIT APPLICATION F19RM <br /> SITE <br /> MITIGATTTTTTTTT�N <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7DUNI�V L� <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) �; n <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 z <br /> (209) 468-3449 cM ~ F7111M 2E �- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED cN– <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 cotm�Iiance 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 /> 16777 Howland Road Louise Ave. Lathrop CA 95330 Assessors <br /> WELL Location Cross Street City p Zip Parcel# 198-180-09 <br /> PROPERTYOwner J.R. Simplot CompanyAddress16777 Howland Rd. City Lathrop CAzip95330 Phone#209/858-2511 <br /> Spectrum <br /> C-57Contractor Exploration, Inc.Address 2365 Wigwam Dr. CityStock ton ziF95205 Lic#512-268Phone#209/465-8712 <br /> Geornatrix 2444 Main St. <br /> Consultant/)6XI ENXr)4X0kr Consultants, In Address K11 re 21 5 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 /> Ig NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') U DESTRUCTION(choose type below) <br /> []SOIL BORING# []OVER-BORE <br /> WELL# 3 []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?[]YES ANO WELL CASING DIA:2–inch <br /> d EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: 0 STEEL JiiPVC []OTHER: <br /> H VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 6 feet TREMIE TYPE TO BE USED: :AUGERS p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: []Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 31 <br /> 0 SOIL BORING []HAND AUGER GROUT SPECIFICATIONS: Neat <br /> []OTHER: []OTHER APPROX.BORING DEPTH 25 feet gBOLTED TRAFFIC BOX or H 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 certif at 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 ��� Title/Companyor <br /> Print Name ��� DS_S Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: �/ —5D D/ CV✓zwaC� �l <br /> Application Accepted By / j 1� t �t Date Issued /N�� Area CWQJ.yQI13 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# 002t <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />