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•San Joaquin County <br /> Environmental Health Department SITE <br /> Q - 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.orgtehd UNIT IV <br /> r4 r ENZ�rKtE� Well Permit Application <br /> ENVcC1�MMS K"GAS NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicati8 �a 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 31115.3 and the Standards of San Joaquin County Erroronmental Health Department. <br /> Ripon Assessors 25 <br /> WELL Location 320 S.Stockton Avenue Cross Street 3rd Street Clty Zip 95366 Parcel# 929024 <br /> PROPS Rle <br /> ovmer Pleasant Valley Farms;LLC Atltlrass 320 S.Stockton Avenue City " Zip 95366 Phone# <br /> C.57 Contract or EnProb Atltlress P.O.Box 6093 City Oroville Zip 95966 U�p777007 pho (530)5632019 <br /> Consultant I Sub Cntr ECM Address 660 Baker Street City Costa Mesa-tom prom, (714)662-2759 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> X NEW WELL/BORING (CPT,GEOPROSE,HYPROPUNCH,HAND-AUGER,.QT1(ER") 0 DESTRUCTION (choose type below) <br /> X SOIL BORING# 1 S(a--4;L ;- ` -+..Yate+r�_4&x, DOVER-BORE. DIAMETER <br /> a WELL# p PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS:One geoprobe boring will be installed. Please see attached map. 5f�.12 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE _7 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION g AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE!OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> X SOIL BORING a HAND AUGER GROUT SPECIFICATIONS �J-„�q tj'hc:rN. - <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 40 feet 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Borings will be abandoned with neat cement grout. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cert-tfy that 1 have prepared this application and thatthe work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed x � E--t'"C6'3---- Title/Company Pr°9ram Manager/Environmenfat Cost Management,Inc. <br /> Print Name Binayak Acharya Date !O �II( �'7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z Tio �r .s� r��✓ <br /> WORK PLAN DATED: L,7 L t I .owl <br /> Application Accepted BYr ,� h — ._ e Issued <br /> B n r��rea <br /> Grout Inspection By Date Lt. __ .Final rosD Y �3 <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS; <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# poS2q� <br /> C-57-jz- WC=WAIVER_ C-57 Letter of Authorization to sign permitf�Encroochment doc <br /> EHD 29-02.001 <br /> 622101 <br />