Laserfiche WebLink
eP4�!n. SAN JOAQUIN COUNTY T' � OPY <br /> —�` °c w' �CfJ <br /> 2 r" ENVIRONMENTAL HEALTH DEPART E <br /> " ` 600 East Main Street, Stockton, CA 95202-3029 0 p�T ,I)(IITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www sioov.0Yg/2h� , Z�fU UNIT IV ' <br /> 4tf rdR1', <br /> ENVIRONMENT HEALTH <br /> WELL PERMIT APPLICATION PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora 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. Assessor's i <br /> Well Location City of Ripen dght-al Cross Street Stact'an Sheet City Ripon CA Zip 95366 Parcel# Rune(Cly RNIB W west <br /> Property209 5991( 8V45-10 <br /> Owner urectmo^cmmmnia AddMSS 259 N.Wilma Avenue City Ripon CA Zip 95366 Phone# ( ) <br /> C-57Contractor Precision sampling Inc(PSI) Address 2365OYgwam Dr. City Stockton CA 'Zip 95205 LIC# 636387Phone <br /> Consultant/Sub Cntr ATC Associates Address 1117 Lone Palm Ave.Suite 201 City Modesto,CA LIG# Phone (209)579-2221 <br /> GIS COOrdlnates:X 3]°44'16.16"N y 121°7'27.21"W ,Township 2S Range BE Section <br /> 30 <br /> WORK TO BE PERFORMED: <br /> N NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE.TYPE BELOW) <br /> H SOIL BORING#.HP<,HPsHPb <br /> tcnn°^ea^n ❑OVER-BORE DIAMETER _ <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:Temporary soil bonngs to Called groundwater samples at approz 38 and 65 feet bgs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Inch El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION- ❑AIR HAMMER/DRIVEN- CASING THICKNESS Nona TYPE OF CASING:❑STEEL ❑PVC 9 OTHER None <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 65 TREMIE TYPE TO BE USED❑AUGERS]HOSE <br /> ❑AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)CPT GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 9 SOIL BORING OHAND AUGER Rand clear a rive feet GROUT SPECIFICATIONS Neat Cement <br /> I <br /> MOTHER: Hydmpunm GW sample ❑OTHER: APPROX.BORING DEPTH 65 fact logs [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED no (if YES,list speencations in comment seder) <br /> COMMENTS:maDonne:rdnxae.anadmes real nea.namPrmy rn,me:ao-ani.noomad Caoorona awes Pian enlmg dg and n inaucar lwinsa wcir—ou^rea CPT daaa Man emurp,g <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby call ify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation ,a 1 app! able Iffgr\nla}��eyv�s.� / I <br /> Signed u ��1/ `Jf/7L�U'C� Title/Company ATc associates <br /> Print Name Michael D.Sbnke - Date March 30,2010 <br /> / DEPARTMENT USE ONLY �+ <br /> SITE MAP IN UNIT iV FILE,ADDRESS: <br /> I I O it '1_We,S+- SC"CD YI CSL Jt ii P.+ <br /> WORK PLAN DATED: Vi C,+6 <br /> Uk Y 14 . �!2�0 ] 0 _ _ <br /> APPLICATION ACCEPTED BY <br /> ViC,+6r;�i4L IYIC ICUYI )Le� j DAT`Ef ISSUED S- �� AREA 1459 <br /> t GROUT INSPECTION BY 11('.�'(N^I G Rt ruuu 6j i.. q-9-16 FINAL INSPECTION BY DATE -l)-10 <br /> DESTRUCTION INSPECTION BY DATE II <br /> COMMENTS/CONDITIONS: - "f- r'ee 51)'-) b <br /> t� Y,D 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3S03 '3qSOD 7434.1 0661171, -/-2 4-510 SR# 0054 LL <br /> C-57 WC -WAIVER - C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />