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WELL PERMIT APPLICATION r'ORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGAT=,, )N <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNI�JV!L - 1 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 - _ <br /> (209) 468-3449 ci>V. ~ II <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rp' p0q,in crfm�iliance.with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environrmntpl+Health Division. <br /> ) <br /> Assessor's `` = <br /> WELL Location 16777 Howland Road Cross Street Louise Ave-City Lathrop CA zip 95330 parcel# 198-180-09 <br /> PROPERTYOwner J.R. Simplot CompanyAddress 16777 Howland Rd. city Lathrop CAzip 95330 Phone#209/858-2511 <br /> Spectrum <br /> C-57Contractor EXploration, Ine.Address 2365 Wigwam Dr. CityStocktonzic95205 Lic#512-268Phone#209/465-8712 <br /> Geomatrix 2444 Main St. <br /> Consultant/UXX0jX&]CtXr Cons u I t--ants, InCAddress tiwi rP 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 /> 19 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> []SOIL BORING# (]OVER-BORE <br /> K WELL# 3 U PRESSURE GROUT <br /> 'Other:_ Hollow—Stem Auger Grout Specifications: Cement Bentonite Grout <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING MIOLLOW STEM DIA.OF BOREHOLE 8—inch MULTIPLE CASINGS?DYES JKNO WELL CASING DIA:2—inch <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: 0 STEEL NCPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 6 f ee t TREMIE TYPE TO BE USED: )GAUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Nea t <br /> 0 OTHER: D OTHER_ APPROX.BORING DEPTH 25 feet Z:BOLTED 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 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.. �/ e <br /> Signed x ���" Title/Companyjr• 11.1111gWC� /JJ lJ �('�GiNXL� <br /> Print Name �>� D.SS Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: 3D D CV✓2wu G/. P (Il <br /> - <br /> Application Accepted Byk, T' lD Date Issued /N�� <br /> Area CUAAICX <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: n..,- <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> $17 - 47gyG b"l- 6 002,6,0y( <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />