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oFq"•". oo SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> -`�-0;, p Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sioov.org/ehd UNIT IV <br /> LrFORj - --- <br /> WELL PERMIT APPLICATION y /v� /b <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED av <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thi;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 /> Asses519 S. Stockton Ave W Fourth Street Parcel ofs <br /> Well Location Cross Street City Ripon, CA Zip 95366 parcel# 25932025 <br /> Property <br /> Owner Nest16 USA, Inc Address 800 North Brand Blvd City Glendale, CA Zip 91203 Phone# <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lic#485165 Phone 925-313-5800 <br /> Environmental cost 3525 Hyland Ave,Ste 200 Costa Mesa 778024 714-662-2759 <br /> Consultant/Sub Cntr nao-annueJnat. rut. Address Y City Lic# Phone <br /> GIS Coordinates:X �T•TJS--- ,Y '4ZI- • I2� ,Township 2S Range 8E Section 29 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) IN DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ®OVER-BORE DIAMETER Per sen Joaquin county <br /> ❑WELL# V6 F ®PRESSURE GROUT ardinante code sectmn 9-1115.6, <br /> ❑'OTHER Air GRRODU,,T SPECIFICATIONS subsection 6.3 <br /> COMMENTS: Well completion log attached � v l 6z ""�- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 611 \� <br /> Cl MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ `V <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ff PVC ❑ OTHER <br /> ®VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL B TREMIE TYPE TO BE USED❑AUGERS❑HOSE 1 <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 /> 24 ' <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,lis(s0ecifion <br /> caus in comment section) <br /> COMMENTS: <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 /> Regulationsand all anulicahla Caufemia Laws. <br /> 1� Project Manager, Environmental Coat Management <br /> Signed _ "�""°'a' �'�- Title/Company <br /> Print Name <br /> Binayak Acharya Date September 16, 2009 <br /> �7 <br /> ''\\ DEP RTMENT USE ONLY 1"06) -0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 23 V 9q <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED g / AREA O6 <br /> GROUT INSPECTION BY FINAL INSW9DATE <br /> DESTRUCTION INSPECTION BY v y ((DATE V-1 <br /> pp '' ` <br /> COMMENTSICONDITIONS: U i �'rfiMrCY�I. Wcns 7 I'� Gug L1V <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTEDCHECK# RECV'D BY TE PERMIT/SERVICE# INVOICE <br /> WD I 1e2 6 R# <br /> C-57 WcV WAIVER C57 LETTER OF AUTHORI ION TO SIGN PERMIT _ENCR C <br /> EH029-07 11/SPo](WEB) FILE C O P " ELL PERMIT APP <br />