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f *s <br /> l . . SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www,si.gov.org/ehd UNIT IV <br /> Me <br /> S WELL PERMIT APPLICATION <br /> M <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 /> Joaqu' C-yunty Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. (1�(�1��..��'��'��II D,,,,t <br /> Wel cation Z23 Stockton Avenue Ri on, CA 9536fi Assessor's <br /> MW <br /> Cross Street City p Zip Parcel# <br /> Pro rty 209-599-2108 <br /> Owner City of Ripon Address 259 N. Wilma City Ripon, CA Zip 95366 Phone# <br /> C-57 Contractor Boart Longyear Address 1333 West 9th Street City Upland, CA Lic#694686 Phone 909-946-1605 <br /> Environmental coal, <br /> Consultant/Sub Cntr Management, mc. Address 3525 Hyland Ave,Ste 200 City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> GIS Coordinates:X 63608_ 91,29 ,Y 2089970 .44 Township 2S Range 8E Section 29 <br /> -12 .1 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CP OPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ' ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ElSOIL SO G y / ElOVER-BOREDIAMETER <br /> ®WELL# M-54C El PRESSURE GROUT <br /> ❑`OTHERGROUT SPECIFICATIONS <br /> COMMENTS One wel to be installed, per Central Valley RWQCB-approved Work Plan. Encroachment Permit Attached. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `V,''a <br /> MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 22 i, W <br /> ❑EXTRACTION ❑ Schedule 40AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:D STEEL ®PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL "' TREMIE TYPE TO BE USED❑AUGERS❑HOSE S <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') \ <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONAtentonite and cement <br /> p I <br /> ❑OTHER: 91 OTHER: Sonic rig APPROX.BORING DEPTH feet Q R1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSE (if YES,list spedfrations in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS V1 <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 <br /> Regulations.and all aoolicable California Laws. <br /> Signed _ "�T�"^'�^`- "a Title/Company Project Manager, Environmental Cost Management <br /> Print Name Binayak Acharya Date November 16, 2009 <br /> 1� D PARTMENT USE ONLY Zp <br /> SITE MAP IN UNIT IV FILE,ADDRESS: CpA-70 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DA I AREA �t <br /> GROUT INSPECTION BY Z FINAL INSPECTION BY J 4 44K DATE�Pi d <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATY PERMIT/SERVICE# INVOICE <br /> 7,401 I // ( R# <br /> C-57 J WC y -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN E MIT Vr ENCROACHMENT DOC <br /> EHD294H 11I5Mt(WEB) 0_/;31L ERMIT APP <br />