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WEAPERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />- (209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />C7 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 San Joaquin County Public Health Services, Environmental Health Division. <br />Assessor's <br />WELL Location -2401 Mc Aurthur Dr.—Cross street _Grantlinecity _Tracy, CA_zip_95376_Parcel#. <br />PROPERTY Owner Leprino Foods—Address-2401 Mc Aurthur Dr._City_Tracy, CA_zip_95376_Phone#_209-833-4243_ <br />C-57 Contractor V&W Drilling_Address_100 5th St._Citr Isleton, CA_zip_95641_Lic#_720904_Phone#_916-777-4100_ <br />Consultant / Sub contractor—HSI GeoTrans_Address_9101 Harlan St., Suite210_City_Westminster, CO_Phone#_303-426-7501_ C <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />[] NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) [X] DESTRUCTION (choose type below) <br />[] SOIL BORING # [] OVER -BORE <br />[] WELL # [X] PRESSURE GROUT <br />*Other: GROUT SPECIFICATION � <br />COMMENTS: See Attached Work Plan <br />TYPE OF WELL <br />INSTALLATION TYPE <br />[X] MONITORING <br />[X] HOLLOW STEM <br />[] EXTRACTION <br />[] AIR HAMMER/DRIVEN <br />[] VAPOR <br />[] MUD ROTARY <br />[] AIR SPARGE <br />[] PUSH POINT <br />[] SOIL BORING <br />[] HAND AUGER <br />[] OTHER: <br />[] OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE _8 in.—MULTIPLE CASINGS? [] YES [X] NO WELL CASING DIA:_2 in._ <br />CASING THICKNESS _Sch 40_ TYPE OF CASING: [] STEEL [X] PVC p OTHER: <br />DEPTH OF GROUT SEAL 2 ft. TREMIE TYPE TO BE USED: [] AUGERS []HOSE <br />GROUT SEAL PUMPED: [] Yes [X] No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) S <br />GROUT SPECIFICATION Portland Type II <br />APPROX. BORING DEPTH 20 ft. a BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED?—none— (if YES, list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />NIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br />Signed <br />Print Name <br />SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br />Application Accepted By Date Issued Lb Area <br />Grout Inspection By ` r, e,. Date tO 1 t Final Inspection By ( c�� Date O l D <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />INVOICE <br />3S -0Z, <br />46o.oc,t <br />Ib <br />IC?1 od q Z-1 6 <br />C-57 WC/WAIVER C-57 Letter of Authorization to sign permit cr�a5hment doc 9/12'/00 <br />