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p 'd San Joaquin County "!'`�•, <br /> �� <br /> . p?; EnvTrOnmental Health Department �Y 4'` ' SITE <br /> 60 <br /> 600 E. Main Street, Stockton, CA 95202-3029 ` ITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: N~v.s' ov.or /ehd <br /> Jg g 0'UNIT IV <br /> Well Permit Application �t�s°f'atS�►t� Th` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ay iiN pFPARTt�ls ` <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> MILGEO AVE/FRONTAGE ROAD/ARC WAY ROW M ILGEO/FRONTAGE/ Assessors <br /> WELL Location CITY OF RIPON Cross Street City RIPON Zip 95366 Parcel#nLR <br /> PROPERTY CITY OF RIPON <br /> DEPT OF ENGINEERING 259 NORTH WILMA AVE RIPON 95366 209-599-210$ <br /> Owner Address City Zip Phone# <br /> ALL WELL ABANDONMENT 3809 PLEASANT VALLY RD PLACERVILLE 95667 848359 800-948-1355. <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultantl50bcnFED GEO ENVIRONMENTALAddress837 SHAW ROAD CitSTOCKTON Li680227 phone# 209-467-1006 <br /> GIS Coordinates:X Y Township Y Range Section <br /> WORK TO BE PERFORMED: <br /> d NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) tO DES T RUCTION (choose type below) <br /> 0 SOIL BORING# a OVER-BORE. DIAMETER <br /> U4NELL# MW-6, MW-7, MW-8, MW-9 D PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )9WiONITORING HOLLOW STEM DIA,OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL VVEt_I_CASING DIA: 2 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SCHED 40 TYPE OF CASING: 0 STEEL B)PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL41'/11' TREMIE TYPE TO BE USED: f[AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )gYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL-BORING 0 HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH 50'/30' 0 BOLTED TRAFFIC BOX or '0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS:MW-6 AND MW-9 TD: 50' WITH 5' SCREEN//MW-8 AND MW-9 TD: 30' WITH 15' SCREEN, <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 in accordance with San Joaquin <br /> County Ordi a �c�e , ales a d'Regulations, and all applicable California State Laws. <br /> Signed x Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name ARTHUR DEICKE Date 10 APRIL 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t5 Cw-,, <br /> WORK PLAN DATED: -021202 ^ {,A 1. 2 & i1 IOIV16' <br /> p C� <br /> Application Accepted By Date Issued J U <br /> Area <br /> Grout Inspection By Date ! Final Inspection B Date <br /> Destruction Inspection By Date <br /> COMMENTS l CONDITIONS: W d S X581 G— r <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �SUf9SR# <br /> $? <br /> t5 C-57_ WC--WAIVERC-57 Letter of Authorizafion to-sign-permit_ Encroachment doc �.. . <br /> E H D 29-02-001 web , a <br /> 6/22/04 __ V! <br />