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WE*DERMIT APPLICATION IO,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 /> (209p 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 <br /> San Joaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> WELLLocation Facer Ripon Tract 301 -Cross Street Parallel Ripon Zia Assessors <br /> My 95366 Parcel" 261-16-02 <br /> PROPERTY Owne,US Army Corps of Engi &§ P.O. Box 1229 City Oakdale zi 95361 phone#(209)881-3517 <br /> c•sTContraetoSPectrum Exp lorat io c. 2365 Wigwam Dr. City Stocktottp 95201, 226$hone#(209)465-8712 <br /> Consultant/Sub Contractor ERM West Address1809 N. Helm Ave.CitFYesno ULT phone#(559)452-8010 <br /> GIS Coordinates:X Y Township T.2S Range R•8E. Section 29 <br /> WORK TO BE PERFORMED <br /> NEW WELL!BORING(CPT.GEOPROSE.HYOROPUNCH,HAND-AUGER.OTHER-) 0 DESTRUCTION(choose type below) <br /> Q SOIL BORING 0 SR—MW9 0 OVER-BORE <br /> -Other. <br /> (j WELL T a PRESSURE GROUT <br /> COMMENTS. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 6 r MULTIPLE CASINGS?0 YES XNO WELL CASING OIA: NA <br /> ]EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SIA TYPE OF CASING: U STEL 9 PVC 0 OTHER: <br /> ]VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED: GAUGERS UHOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: a Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .$SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or l]STOVE PIPE <br /> ]OTHER: 0 OTHER CONDUCTOR CASING PROPOSED? (if YES. list specifications here): <br /> :OMMENTs: This is a stratigraphic boring only. No weil will e insralted. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS ..r� <br /> nereoy certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances.State Laws, les <br /> and Reguiations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance o e work <br /> or which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractors hinng <br /> :ont ting s ature certifies the following: 'I certify that in the performance of the work for wnich this permit is issued. I shall employ persons subject to <br /> N RKE.RS'C MPENSATION Laws of California.' <br /> THEA PLICA �iS/T CALL 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIONS. C003 <br /> signed x — Title Date <br /> SEE ITEM IN UNIT IV WORK PLAN DATED "4 <br /> 11 �� �� DEPARTMENT USE ONLY <br /> ,pplication Accepted By �YJV WU\�� Datelssued <br /> ;rout Inspection By DateO i y fl��-c,i'tnr'o� EOate 0 <br /> C:D Final Inspection d /t' �' 0 <br /> R <br /> :estrucion Inspection By Date 9 <br /> �OMMENTS/CONDITIONS: UNT` <br /> OPO RSER allQS <br /> ACCOUNTING ONLY: AID# i FAC# yu-- E <br /> PE CODES FEE INFO AMOUNT REMITTED HECK# ASH I RECEIVED BY I DATE I PERMITlSERVICE REQUEST NUMBER I INVOICE 'I <br /> C-57 LICENSED CONTIL3CTOR N1UST SIGN LICENSE &WORKERS' CONIPENSATION DECLAR kTION <br /> NIT IV- 6/23/99 /sign bkog/MI <br />