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. C(OPY <br /> SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 7, < SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 idein compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WellLocation519 S. Stockton Ave Cross Street W Fourth Street City Ripon, CA Zip 95366 Parcel# 25932025 <br /> Property <br /> Owner Nestle USA, Inc Address 800 North Brand Blvd City Glendale, CA Zip 91203 Phone# <br /> C-57Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lic#485165 Phone 925-313-5800 <br /> Environmental Cost <br /> Consultant/Sub CntrManave,nent, ln�. Address 3525 Hyland Ave,Ste 200 City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> 6381081.85 2090769.53 <br /> GIS Coordinates:X_ 37.��.. ,Y Township 2S Range 8E Section 29 <br /> WORK TO BE PERFORMED: <br /> [91 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCk,HAND-AUGER,OTHER-) E]DESTRUCTION(CHOOSE TYPE BELOW) <br /> F-1SOILBORING# ❑OVER-BORE DIAMETER <br /> ®WELL# M-52B an M-53B ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENT9wo wells to be installed, per Central Valley RWQCB-approved Work Plan. No access agreement required; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING I31 HOLLOW STEM DIA.OF BOREHOLE 4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 2" <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> 2' above <br /> []VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL screen TREMIE TYPE TO BE USED❑AUGERS❑HOSE N <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS bentonite and cement (� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Both to 50 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE V <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) f <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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed _ « ir �� 41-=.:aa__ Title/Company Project Manager, Environmental Cost Management <br /> r <br /> Print Name Binayak Acharya Date November 16, 2009 <br /> DEPARTMENT US NLY �4/0,04/0,0SITE MAP IN UNIT IV FILE,ADDRESS: '71jQ4 <br /> WORK PLAN DATED: 40 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA If <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> No �/ 1LK�� PR# <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />