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5 <br /> WEAERMIT APPLICATION AM SITE <br /> MIlfIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> !ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location-2401 Mc Aurthur Dr.—cross street_Grantline_city_Tracy, CA_Zip_95376_Parcel# <br /> PROPERTY Owner_Leprino Foods—Address-2401 Mc Aurthur Dr._cry_Tracy, CA_Zip_95376_Phone#_209-833-4243_ <br /> C-67 contractor_V&W Drilling_Address_100 5th St._city_Isleton, CA_Zip_95641_Lic#_720904_phone#_916-777-4100_ <br /> consultant/SubContractor_HSI GeoTrans_Address_9101 Harlan St., Suite210_city_Westminster, CO_Phone#_303-426-7501_ <br /> GIS Coordinates:X ,Y ,Township Range Section _ <br /> WORK TO BE PERFORMED: <br /> []NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [X]DESTRUCTI 0 OVERSBORE(chooe type below) <br /> 0 SOIL BORING# <br /> 0 WELL# [X]PRESSURE GROUT <br /> 'Other: GROUT SPECIFICATION <br /> COMMENTS: See Attached Work Plan <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X]MONITORING [X]HOLLOW STEM DIA.OF BOREHOLE-8 in.—MULTIPLE CASINGS?BYES [X]NO WELL CASING DIA:_2 In._ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_Sch 40_TYPE OF CASING: []STEEL [X]PVC 0 OTHER <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL-2 ft. TREMIE TYPE TO BE USED: 0 AUGERS OHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes [X]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> []SOIL BORING []HAND AUGER GROUT SPECIFICATION Portland Type II <br /> 0 OTHER: Il OTHER APPROX.BORING DEPTH 20 ft. 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?_none_(if YES,list specifications here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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,State Laws,and Rules and Regulations of the San Joaquin County. <br /> L NIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Signed x I TRIe/Company <br /> Print Name V1, Date (6 S Ob <br /> �IL� 1007 \y� OVfi�SrS��J <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED — <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued I C, m- Area <br /> Grout Inspection By Date Final Inspection By —Date O 1 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SE VICEREQUEST# INVOICE <br /> 3 so z .4 60. 0 C7 l -fl b to 9 ca Ca z <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/12/00 <br />