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San Joaquin County <br /> a Environmental Health Department I �J fE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ; wunroATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd { \(�j Fp p h' [VN'� <br /> `�N tRONMENY IICIi'�I i.IV <br /> Well Permit Application PFRN1&T,�7-71VICt <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 Develooment Title,Chaoter 9-1115.3 and the Standards of San Joaquin County Environmental Health nPnartn,Pnt. <br /> 16777 S Howland Road Louise Ave Lathrop 95330 Assessors 198-180-05 <br /> WELL Location Cross Street_ _City Zip Parcel# <br /> PROPERTY R.Simplot Company F 16777 Howland Road Lathrop 95330 <br /> Owner _Address City Zip_ hone# <br /> C-57 Contractor Fddress <br /> V&W Drilling P. _City_ <br /> O. Box 416 Zip Iseton 95641 ij,# Fhone#_720904 1-916-777-4100 <br /> Consultant/Sub Cntr Neil O Anderson and Asso ddress.902 Industrial Way City_Lodi Li(* 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*) p DESTRUCTION (choose type below) <br /> &SOIL BORING# a OVER-BORE. DIAMETER <br /> WELL# LP-5B 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: installation of LP-5B in new location <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> g MONITORING H HOLLOW STEM DIA.OF BOREHOLE—8 inchp MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2_inch_ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS sch 40 TYPE OF CASING: 0 STEEL MPVC Q OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 8 feet TREMIE TYPE TO BE USED: N AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING a HAND AUGER GROUT SPECIFICATIONS?gal H2O, per 94 lbs cement, plus 3 lbs bentonite powder <br /> a OTHER: a OTHER APPROX.BORING DEPTH 25 feet a 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 Certify that I lhye prepared this application and that the work will be done in accordance with San Joaquin <br /> County Olydinances, R'u' s and Regulations,and all applicable California State Laws. <br /> Signed x _ Title/Company_Senior Geologist-Neil O.Anderson&Assoc <br /> Print Name J es Robinson Date December 4, 2006 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: q� <br /> Application Accepted By Date Issued 7 br �� Area <br /> Grout Inspection By Date > 1 / C�C Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> cI`l L), 'V:- " S I (�. �� /t (z /`� ()t SR# t)W2 r <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 />