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'"VSan Joaquin County <br /> Environmental Health Department D ECE8 TE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN 0 4 P00-UNIT IV <br /> Well Permit Application SAN Jo AQUIN COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU�/,1t��IRONMENTAL HEALTH <br /> DEPT. <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 /> Assessors <br /> WELL Location 17000 E. Hary 120 Cross Street Murphy CIty Ripon Zip Parcel# Sea arrarhed <br /> PROPERTY <br /> OwnerThe Wine Grouo Address17000 E. Hwy 120 city Rinon Zip93366Phone#209-599-9000 <br /> c-67contractorGregg In—Situ Address 950 Howe Rd. city Martinezip94553LicA656407Phune# 925-313-5800 <br /> Consultant/&AX%ffj ennedv/.Tankc Address 622 Folsom St. City$.F. Lic# Phone#415-243_-250R <br /> GIS Coordinates:X-121.0987 ,Y37,7989 ,Township--2,'j_Range RR Section 4 <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,0RUMUM HYDROPUNCH,NXKDHW,9 [OTHER*) D DESTRUCTION (choose type below) <br /> XQSOIL BORING# throe — DOVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE/OZONE ZPUSH POINT(GP or CPT)GROUT SEAL PUMPED: aYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATION.. NR a� <br /> D OTHER: D OTHER APPROX.BORING DEPTH 8 eet D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YES,list specifications 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 in accordance with San Joaquin <br /> County Or i noes, Rules and Regulations,and all applicable California/State Laws./ /� <br /> Z:�P Title/Company (,�U/s� S2Ik—",l /H'4 <br /> Print Name 1'I 1, /C l'µet (.. /Lirc Date / 3/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1-Z0 <br /> WORK PLAN DATED: 6 ( I t I r,14 <br /> Application Accepted By I W A 111� Date Issue tl l /b�Os Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ;t'qOI ,&q• a I jq ?2 10 1 b o SR# oo yo8-. S <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> E1D 29-02.001 <br /> 6/22/04 <br />