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San Joaquin County F'oECL - L4- --- <br /> Emirontneutal Health Department SITE <br /> (" 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 NOV - fROMATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.s}gov.of?/&d � <br /> 1V <br /> Well Permit Application ENVIRONMENT 4AITt PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Appkidlon is hereby made ro San Joaquin County tar a pemnit to contract crafter Install the work described, This application is made in caxnplianca vAh San <br /> Joa(lim County Development Tide,Chapter S.1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 2401 Mac Arthur Drive Cnsss Sheet East Grant Line RdOdy Tracy Zip 95376 parcew 213-070-50 <br /> PROPERTY <br /> Ormer.Leprino Foods Company Address 2401 Mac Arthur Drive City Tracy tin 95376 phora# (209)833-4266 <br /> C-67 Contractor scads Dulling lnaTEGpddrags 36320mec Circle CRancho_ Cordova�P 95742 717510 pF (916)636-1169 <br /> Consultant t Sub CflS1.GeoTrans.Inc Addresa363 Centennial Pkwy,Ste 2100 Louisville,C R02 p(nol (3031665 390 <br /> GIS Coordinates:X UTM 639560E .Y 417992ON Tmmship Range Section Land Grant <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING (OPT,GEOp HYDROPUNCH,HAND.AUGER OTHEW) DESTRUCTION {cnooaetypebeow) <br /> X QBORING# QOVER-�iE. DIAMETER <br /> Q PRESSURE GROUT <br /> 0.0L GROUT SPECIFICATIONS <br /> COnMIMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONS SPECIFICAUKINS <br /> Q MONITORING Q HOLLOW STEM DIA.OF B E 100 M1JL T IPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> $EXTRACTION 0 AIR HAMMEMDRIVEN CASING I ICKN 7, ✓7F CASING: Q STEEL Q PVC Q OTt : <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT 5 ft TREMIE TYPE TO SE USED, Q AUGERS Q HOSE <br /> BAIR SPARGE/OZONE 0PUSH POINT(GPor CPT)GROUT SEAL PUMP : QYea RNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING 0 HAND AUGER GROUT SPECIFICA DNS_Per ASTM D5092 _ <br /> Q OTHER: fl OTHER APPROX.SORT DEPTH 5 ft 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTORC NG PR No (it YES,list spadficatihms in comment section) <br /> COMMENTS:Two 2"product recovery wells to approx 20 ft;one gradient control ell to approx 25 ft.in accordance with RWDCB approved plan <br /> NOTE: OFFSITE BORINGS REQUIRE ACESS AGREEM T OR ENCROACHMENT PERMITS. <br /> 48 WORKING H/ad <br /> NOTICE REQUIRED FOR NSPECTIONS. <br /> I hereby certify that 1 have prepared this appn and that the work will be d 1e in accordance wif,I�aa1 Joaquin <br /> County Ordinances, Rules and Regulations, l applicable California State La s. r <br /> Signed Tilt=lCorriparvy <br /> Print Name Data I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Applicators Accepted By Date Issued Area <br /> Grout inspection B't Dat Final inspection By Data <br /> Deehucticn Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK RECD BY DATE PERMIT i SERVICE REQUEST INVOICE <br /> SR# <br /> C-57_ VdC=WAIVER_ C-57 letter of Authorization to sign permit_Encroachment dor_ <br /> �� <br /> A01 <br />