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SAN .IOAQUIN COUNTY ! P <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> sa l�„tr Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> lyV/1 WELL PERMIT APPLICATION <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 /> jiaquin Co nt Development Title,chapter 9-1115.3 and the Standards Of San Joaquin County Environmental Health Department. N/A City <br /> '� 33p. INdU9TEtAl., Assessor's <br /> Location 6 ross Street �V V R� City Ripon', CA Zip 95366 Parcel# Street <br /> ..perty <br /> Owner City of Ripon Pu&ic Works Address 259 N. Wilma Avenue City Ripon, CA 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 /> en.ironmmeal cost 3525 Hyland Ave,Ste 200 Costa Mesa 778024 714-662-2759 <br /> ConsultanUSub Cntr maoaoemeot. Ino. Address Y City Lic# Phone <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-) [Zn DESTRUCTION(CHOOSE TYPE BELOW) <br /> [I SOIL BORING# 1, X❑OVER-BORE DIAMETER Per sao ooaaum c.ssty <br /> ❑WELL# PRESSURE GROUT ordinance Code section 91115.6, <br /> [-I-OTHER Qt O� GROUT SPECIFICATIONS sensectto., 6.3 <br /> COMMENTS: Well completion log attached; A cess agreement in place with City <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4" V <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL IfPVC ❑ OTHER <br /> 8' <br /> IN VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 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') C <br /> C <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> 26.5' <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,lmt specifcewns in comment section) <br /> COMMENTS: r <br /> r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS �l <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 `S <br /> Regulations,and all applicable California Laws. Yi <br /> Signed )Yrw Title/Company Project Manager, Environmental Cost Management <br /> Print Name Binayak Acharya Date September 16, 2009 <br /> J2 <br /> DEPARTMENT USE ONLY <br /> Z J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY �/�-_ ^"T �'-'r-a-�e � ,}MIf: AREA w <br /> GROUT INSPECTION BY _ '+• •- " i _ FINAL INSPECTION BY _rLD <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE t,-'�i <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 4 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNERMIITWT ENCROACHMENT DOC <br /> EHD 2&0111/5,0](WEBI <br /> t/ V ' -,,1 OPY <br />