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WELOPERMIT APPLICATION *RM UNIT IV <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 /> 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 descnced. This application is made in compliance with <br /> San Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services.Environmental Health Division. <br /> .,l Z assesso s <br /> WELL Location 435 N. MapleP f) Main Street Ripon 95366 <br /> Cross Stree city P Zp Parcel# 259-020-19 <br /> PROPERTY Owner Ripen�M^ 1 roress�Q e City Ripon zp95366Phone# (209)599— <br /> At <br /> c-sTContractor Spectrum ExploratiInc. 2365 Wigwam Dr. <br /> Ci Stockto 95205 . 51226 (209)465-8712 <br /> City $p Lic# hone# <br /> Consultant/Sub Contractor ERM West Address 1809 N. Helm Ave-City Fresno Lc Phone# (559)452-8010 <br /> GIS Coordinates:X , Y , Township T•2 S• Range R.BE. Section 19 <br /> WORK TO BE PERFORMED <br /> ANEW WELL/BORING(CPT. GEOPRC8E, HYOROPUNCH, HANO-AUGER,OTHER-) Q DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> (kWELL#M-27A rr-c-rcr--ir>=)0-7 M-27D Q PRESSURE GROUT <br /> 'Other: n G <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'rr&MONITORING o HOLLOWS cM DIA.OF BOREHOLE 8"&12 -4AULTIPLE CASINGS?)h YES Q NO WELL CASING DIA:2n <br /> 0 EXTRACTION 0 AIR HAMMER/ORIVEN CASING THICKNESSSched. 80 TYPE-OF CASING: 0 STEEL IfPVC 0 OTHER: <br /> 0 VAPOR ( MUD ROTARY DEPTH OF GROUT SEAL see commen"EMIE TYPE TO BE USED: Q AUGERS UHOSB)VC pi <br /> a AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 270' 4 BOLTED TRAFFIC BOX or :7 STOVE PIPE <br /> 0 OTHER:_G OTHER CONDUCTOR CASING PROPOSED? ( if YES.list specifications here): <br /> COMMENTS: The hentonite grout seal shall be to the depth o above and beloalS. <br /> Multiple Completions. Approximate Screened intervals: 90-1 - - -250' <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 County Ordinances. State Laws, and Ruies <br /> and Regulations of'he San Joaquin County. Homeowner or licensed agents signature certifies the following: "I certify that in the performance of Me work <br /> for which this permit is issued,I shall not employ persons subject to NORKERS'COMPENSATION Laws of California." Contractor's hiring or suo- <br /> contracting signature certifies the following: -f certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WORK" „ MPENSATION Laws of Califomia.' <br /> THE APPLICANT ST CALL 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIONS. <br /> Signed z Title Date /O& DO <br /> SEE SITE MA N UNIT IV WORK PLAN DATED r DY <br /> DEPARTMENT USE ONLY nr MUT <br /> Application Accepted By Date Issued — -a 0 <br /> 3rout Inspection By. I X:1-1,1anr�e4 Date r O Final Inspection By pateI! <br /> Destruction Inspection By Date ')" <br /> COMMENTS I CONDITIONS: VNj <br /> p11` SEP� 1J�y1�1i <br /> ACCOUNTING ONLY: AID# i FAC# p0oha�Ft�SP' <br /> P <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK" ASH RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE <br /> Z%l (Ohf/4 SR#M24EQY I <br /> Col LICENSED CONTRACTOR NItiST SIGN LICENSE&WORKERS' CONVENSATION DECLARATION <br /> JNIT IV-6/23/99/sign bkpg/MI <br />