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DIY San Joaquin County ECENIEW <br /> c Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 JUL 1 7 2MFTIGATION <br /> \ (209)468-3449 Fax: (209)468-3433 Web: www.sj9ov.org/ehd.VIR0NMEN1' HEAR IT IV <br /> S /Fait ` Well Permit Application C IT/SERVICES <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 Tale,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> S.Stockton Avenue 5'���`4th Street Ripon 95366 Assessors X59-3'�- <br /> 519 SStktA <br /> WELL Location Cross Street City Zip Parcet# 25�7-33L - <br /> PROPERTY Nestle USA, Inc same as well location Ripon yc � <br /> Owner Address City Zip Phone# <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road Road CltyMartinez Zip 94553 Lic#455165 Phone#(925).913-5800 <br /> Consultant/Sub Cntr ECM Address 660 Baker Street Cry Lic# Phone# (714)662-2759 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> D SOIL BORING If D OVER-BORE. DIAMETER <br /> D WELL#- D PRESSURE GROUT <br /> X'Other Soil was Borina btT•3Ci l .5 GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE_Y'J�P D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes X No (NOTE: MAXIMUM' FREE-FALL DEPTH IS 30') <br /> X SOIL BORING 0 HANDAUGER GROUT SPECIFICATIONS «'ti� D r "ex -<- <br /> a <br /> CD OTHER: 0 OTHER APPROX.BORING DE 1 D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES,list spermcations in comrt1ent section) <br /> COMMENTS: 13 borings will go up to 5 ft bgs and 2 up to 25 feet bgs S (7 (� d / bt/ �'_�; <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x ; �:> &Af=?2 - Tale/Company Program Manager,ECM <br /> Print Name Blnayak Acharya Date <br /> DEPARTMENT <br /> r USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRE�SyS:-1 23 ZnCLt I t , I t d I <br /> WORK PLAN SAAB: SN�Xn u`Fcd D C lJ l�t� 6-L43001-26125) G <br /> Application Accepted By Date Issued r I-1 (� Area 47 <br /> Grout Inspection By Date -7 LIA ILL-Final Inspection By (/�tv1 Date L O <br /> Destruction Inspection By Dai4 ' <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 /> aq o i T5 19 377 1 1 sR# Li-ly 93 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E D 29-02-001 <br /> 6/22104 <br />