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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street,Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sigoV.oralehid UNIT IV <br /> d(IFOFN; <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 the San Joaquin County Environmental Health Department. <br /> Site Location 2401 North MacArthur Dr. Cross Street Grant Line City Tracy Zip 95376 APN <br /> Property <br /> Owner Leprino Foods Company Address 2401 North MacArthur Dr. City Tracy Zip 95376 Phone (209)833 4260 <br /> C57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic 485 165 Phone(925)313-5800 <br /> ConsultantlSub Crdr GeoTrans.Inc Address 363 Centennial Parkway"Ste 210 City Louisville-CO Lic 80027 Phone (303)665-4390 <br /> Billable Party GeoTrans,Inc. Address 363 Centennial Parkway,Ste 210 City Louisville,CO Zip 80027 Phone(303)665-4390 <br /> GIS Coordinates:X 639529 meters East y 4179752 meters North(UTM Zone 10) <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ©WELL IDs Existing we MW-17 is damaged. Existing casing and screen will be overdrilled and re2laced with no location or design changes. <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _©MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 8-inch O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: 0 STEEL IN PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL. 9 fee[ TREMIE TYPE TO BE USED: ®AUGERS 0 HOSE ❑PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes [3 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _I]INJECTION(i.a.Air Soame.Ozone l❑HAND AUGER GROUT SPECIFICATIONS ASTM D-5092 <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 23 feet [3 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) <br /> _#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 23 FT <br /> WELL Dstlemesd wellcminy/vcreenro be ovrrdNlea,remov i;yew wdi inrrenea io Me r.me burin¢leo nMouonmem[]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Senior Engineer/Geo Trans,Inc. <br /> Print Name Brendan Shine T- Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITEDREISS z�l U t�fi�f.QT�7t-. <br /> WORK PLAN DATED SsIIa 1I D <br /> APPLICATION ACCEPTED BY a_. DATEISSUED AREA <br /> GROUT INSPECTION BY 01 3 1 n FINAL INSPECTION BY I/t�. A. r t, g\ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �. 13 $122X I IZz L53°i I (aQ g Z� ro SR# 16016S6 <br /> RO# <br /> 3500 <br /> 36b �s3tir PR# <br /> z90o <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />