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WE . PERMIT APPLICATION ,-ORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) � � � ' IV, <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 MAY 1 ?UU1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicati( is/n'falde,in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Envirdrimental Health Division. <br /> Assessor's <br /> WELL Location 16777 Howland /toad Cross Street Louise Ave.City Lathrop CA zip 95330 Parcel# 198— 160-09 <br /> PROPERTYOwner J.R. Simplot Companygddress 16777 Howland Rd. City Lathrop CAzip95330 Phone#209/858-2511 <br /> Spectrum <br /> C-57Contractor Exploration, InC.Address 2365 Wigwam Dr. CityStocktonzip95205 Lic#512-268Phone#209/465-8712 <br /> Geomatrix 2444 Main St. <br /> Consultant/)0WEX&%Mr Consultants, Incladdress SuirP 219 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 /> 0 SOIL BORING# p OVER-BORE <br /> K 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 OPOLLOW STEM DIA.OF BOREHOLE 8—inch MULTIPLE CASINGS?BYES gNO WELL CASING DIA:2—inch <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: 0 STEEL N(PVC BOTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 6 feet TREMIE TYPE TO BE USED: I:AUGERS p HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes 4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: Neat <br /> 0 OTHER: B OTHER APPROX.BORING DEPTH 25 feet ):BOLTED TRAFFIC BOX or p 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, sand egulations, and all applicable California State Laws.. <br /> Signed x �ry� Title/Companyor. <br /> Print Name ��� d SS Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: f�Dj01 c Vy2�✓ $ 4n L-A /? 0q <br /> Application Accepted By �.IkMA�� Date Issued__,d_Z//1) AreaClfR L-t/LkG1!i1 <br /> Grout Inspection By Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: vl-_ <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a- oI 139 ^ �4 r 8S 00.- (, 0 �/-7 <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ 9/27/00 <br />