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San Joaquin County, "OR (G�'� V� <br /> Environmental Health Department "W" SI <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 Wif6ATION <br /> (209) 168-3449 Pea: (209)468-3433 WLb ,wwv sjgov.org ehtl "� '/ (W)VIEt T IV <br /> Well Permit Application ff"p'TIS€ =L', <br /> �t <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 /> Joaquin County Development Title,Chapter 8-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 227 Industrial Avenue 4th Street on Assessors <br /> WELL Location Cross Street City Ripon Zip 95366 pare 25929004 <br /> PROPERTY <br /> Owner California Freight Sales P.O.BOX 365 Ripon Address City P Zip 95366 phone* <br /> C-57 Contractor Gregg Drilling, Inc. Address 950 Howe Road Martinez 925 313-5800 <br /> City Zip 94553 Lic#485165 Phone* ) <br /> Consultant f Sub Cntr ECM Address 660 Baker Street Cin Costa Mesa idt Pnone# (714)6662-2759 <br /> GIS Coordinates:X Y ,Township__Range _Section__ <br /> WORK TO BE PERFORMED' <br /> X NEW WELL I BORING (CPT.GEOPROBE.HYDROPUNCH.HAND-AUGER.OTHER') g DESTRUCTION (ChOOSe type below) <br /> I]SOIL BORING# Q OVER-BORE. DIAMETER <br /> X WELL#_ U PRESSURE GROUT <br /> ()'Other GROUT SPECIFICATIONS <br /> COMMENTS:One monitoring well will be installed. Please see attached map. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCIION SPECIFICATIONS <br /> X MONITORING X HOLLOW STEM DIA,OF BOREHOLE_'I�3 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA. Z�__,., <br /> g EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS SCh-40 TYPE OF CASING: STEEL X PVC Q OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS 9 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUTSEAL PUMPED:X Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland cement with 5%bentonite <br /> a OTHER: 10 OTHER APPROX BORING DEPTH 65 feet X BOLTED TRAFFIC BOX or 0 STOVE PIPE. <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED_—�_ (if YES.list specifications in comment section) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x I „a l <br /> �� <br /> a�— Title/Company <br /> Print Name G2 l/f Li-YA� y _ Date <br /> DEPARTMENT USE ONLY —�� <br /> r <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1/ - I a I 1 -6 (� I <br /> Application Accepted By r i t� _gyp Dale Issued y - � Area in y <br /> Grout Inspection By to _Final Inspection By <br /> Destruction Inspection By Dote - - -- -. a e�)_-y � <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# I RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> DHT}29-02.001 — <br /> 6P_J04 <br />