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• SAN JOAQUIN COUNTY 0 FILE COPY <br /> l�.ak <br /> L <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 9 ' ! 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.siciov.orp/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 Environmental Health Department. <br /> Assessor's <br /> Weil Locatlorl Industrial Ave Cross Street E Fourth Street City Ripon, CA Zip 95366 Parcel# 25938001 <br /> PropertyCalifornia Freight Sales 251 E Fourth Street Ripon, CA 209-599-5418 <br /> Owner Address City P Zip 95366 Phone# <br /> C-57Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lie# 485165 Phone 925-313-5800 <br /> Consultant/Sub Cntr swironmencat Co., <br /> 10�. Address 3525 Hyland Ave,Ste zoo City Costa Mesa LIC#778024 Phone 719-662-2759 <br /> nae 20914 73.250 <br /> GIS Coordinates:X 317. ,, --IZ.I. 12.2- —4,-Township 2S Range 8E Section 29 <br /> �3 1.911 o.au..,vo <br /> 6381955.689 20919 X0.361 <br /> WORK TO BE PERFORMED:6391e63.e91 zo9199'r.191 , <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ® DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# 3 �E.St 464 J�•1 ❑X OVER-BORE DIAMETERrer sen 0...uin co.nty <br /> ❑WELL# ✓E,�b ®PRESSURE GROUT ordinance code section 9-1115.6, <br /> ❑`OTHER GROUT SPECIFICATIONS subsection 13.17 (o.oicor welt.) <br /> Seven Won this parcel. Well completion logs attached; <br /> COMMENTS: A s Agreement in place with property owner and attached or <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2" & 4" <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: V <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> EIVAPOR El MUD ROTARY DEPTH OF GROUT SEAL Be5' an TREMIE TYPE TO BE USED❑AUGERS❑HOSE <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 <br /> Water present Between an <br /> ®OTHER: at -29 fbqs ❑OTHER: APPROX.BORING DEPTH cge I U,. ®BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment seclion) <br /> COMMENTS:Ilccfrny the.wells by hreakin0 thrnl lgh the grout RdAl pi fling nl it the wall racing in whole and thorn grout filling the horrhnla If <br /> during the process of pulling out the casing, the casing Is broken, then over-drilling will be used to ensure proper destruction. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 1 <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 _ 1�;Ye.�...-t�ci�'&'" Title/Company Project Manager, Environmental Cost Management <br /> Print Name Hinayak Acharya Date November 18, 2009 <br /> DEPARTMENT USE ONLY G <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> o Zi- op <br /> APPLICATION ACCEPTED BY DATE ISSUED /5 0 ARE -_ <br /> 9. a3A <br /> GROUT INSPECTION 8Y r '. 'r9\' � ✓ V FINAL I_ T 1 �a 13D '-_'_� - DATE _ <br /> DESTRUCTION INSPECTION BY �`l.ulR./ �^^N" DATE ` .ti�S l,Oq <br /> COMMENTS/CONDITIONS: V1 W�`i P�+S`N�� trdtM�� - � Dt�N" 6" SAY <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> e9 SR# 7 !U <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT rMIDOWEHD29-01 11/5/07(WEB) <br />