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0 SAN JOAQUIN COUNTY FILE COPY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siqov.orq/ehd UNIT IV <br /> 1 <br /> V ./VWELL PERMIT APPLICATION <br /> V � � <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 /> *Ja. mCo myDevelopment Title,chapter 9-1115.3 and the Standarrddssoof� ]San Joaquin County Environmental Health Department. N/A City <br /> ocation 336 INdusrl tp t J�rOSS Street w V F� r` Cit Ripon, CA Zi 95366 parrey�p rs Street <br /> rty +" -- Y P <br /> Owner City of Ripon Pubic works Address 259 N. Wilma Avenue Cit Ripon, CA <br /> City P Zip 95366 Phone# 209-599-2108 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lic#485165 Phone 925-313-5800 <br /> Env1I0I114C11C31 COHC <br /> Consultant/Sub Cntr Management Inc. Address 3525 Hyland Ave,Ste 200 City Costa Mesa Lic# 778024 Phone 714-662-2759 <br /> GIS Coordinates:X 6381831.100 y 2091487.870 ,Township 2S Range BE Section 29 <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) IN DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ©OVER-BORE DIAMETER eer SHn aoaguan covncv <br /> ❑WELL# /_ ®PRESSURE GROUT ordmaneH coda sagctgn 9-1115.6, <br /> El'OTHER 44-C GROUT SPECIFICATIONS s.1 <br /> COMMENTS: Well Completion log attached, greement in place with City <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 IF <br /> 1V,1 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL If PVC ❑ OTHER V' <br /> ®VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL B THEME TYPE TO BE USED❑AUGERS❑HOSE <br /> r <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes Cl No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') -� <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 26.5' +y <br /> ❑BOLTED TRAFFIC BOX OR [I STOVE PI <br /> CONDUCTOR CASING PROPOSED PE <br /> COMMENTS: (if YESspedOcations in mmmem section) <br /> r- <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 /> Signed1�irwa—w{4��'"a`— Title/Company Project Manager, Environmental Cost Management <br /> Print Name Binayak Acharya Date September 16, 2009 <br /> �J2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z30 <br /> WORK PLAN DATED: l� <br /> APPLICATION ACCEPTED BY _ ^-'S4';� .�; }+�( AREA <br /> GROUT INSPECTION BY y/ 1_• FINAL INSPECTION BY - - r DATE <br /> DESTRUCTION INSPECTION BY J �AMa/� DATE k, <br /> COMMENTSICONDITIONS: (_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 21W I <br /> C-57 WC I -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERI/MIIjTWT ENCROACHMENT DOC <br /> EHD29-0111I5/W(WEB) V a *Iftft 0PY <br />