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WELIWERMIT APPLICATION F RM UNIT IV <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209)' 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Aoplication 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 <br />San Joaquin County Development Title. Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br />WELLF. <br />Location aGn <br />t- Rion.Tract 301 Cross Street Parallel A Ripon Zip ParcelR 95366 Assessors 261-16-02 <br />�Y <br />PROPERTY OwnePS Army Corps of EngiA"giA P.O. Box 1229 Cih, OakdaleZ;p 95361 phone# (209) 881-3517 <br />C-57 Contract&ectrum Exploratiorpc. 2365 Wigwam Dr. City Stockton;o 9520t5;51226,h0rte#(209)465-8712 <br />Consultant/ Sub Contractor ERM West Address1809 N. Helm Ave.CitvFresno Litt Phone#(559)452-8010 <br />GIS Coordinates: X <br />, Y <br />Township T.2S <br />Range R. 8E. Section 29 <br />WORK TO BE PERFORMED <br />NEW WELL / BORING (CPT. GEOPROBE, HYDROPUNCH, RANO-AUGER, OTHER-) <br />Q DESTRUCTION (choose type below) <br />�SOIL # SB-MW9 <br />Q OVER -BORE <br />'Other. <br />WELL30RING <br />Q PRESSURE GROUT <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />Q MONITORING <br />Q HOLLOW STEM <br />DIA. OF BOREHOLE 6" MULTIPLE CASINGS? Q YES Q;NO WELLCASING DIA: NA <br />Q EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS NA TYPE <br />OF CASING: Q STEEL Q PVC Q OTHER: <br />Q VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL NA <br />TREMIE TYPE TO BE USED: Q AUGcRS QHOSE <br />Q AIR SPARGE <br />Q PUSH POINT <br />GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />[[SOIL BORING <br />Q HAND AUGER <br />APPROX. BORING DEPTH <br />Q 60LTED TRAFFIC 30X or Q STOVE PIPE <br />\I <br />Q OTHER: <br />Q OTHER <br />CONDUCTOR CASING PROPOSED? <br />( if YES, list specifications here): <br />This is <br />boring No <br />be <br />COMMENTS: <br />a stratigraphic <br />only. weii <br />71TT i <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br />for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractors hiring or sub - <br />cont ting s ature certifies the following: "7 certify that in the performance of the work for which this permit is issued. / shall employ persons Subject to <br />W RKERS' C MPENSATION Laws of California.' <br />\ THEA PLICA ST CALL 48 HRS IN ADVANC FOR ALL RE�Q/JUIRED INSPECTIONSleu - Signed x Title /// <br />Date U w <br />SEE SITE MA?PIIIN UNIT IV WORK PLAN DATED <br />\ DEPARTMENT USE ONLY '\ /� Nl <br />Application Accepted By (u,1� Date Issued ft �V - DID �A�p,,�0 <br />Grout Inspection By —Date—Lc L C-tI Final Inspection By j-'t��tilncc RE Oatelc r' h <br />Destruction Inspection By Date 9 <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# i AC P 3—M04` " <br />c <br />PE CODES I FEE INFO I AMOUNT REMITTED HECK# ASH RECEIVED BY j DATE I PERM M R I INVOICE <br />C-57 LICENSED CONTRACTOR NIUST SIGN LICENSE &WORKERS, CO 1 ON DECLARATION <br />UNIT IV - 6/23/99 /sign bkog/MI <br />