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0 0 <br /> San Joaquin County <br /> ® Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> 1 (209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org(chd UNIT IV <br /> Well Permit Application <br /> E'1v P� NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permil 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. <br /> Assessors <br /> WELL Location R24 S.Stockton Avenue Cross Street 3rd Street City Ripon Zip 95366 paroa* one <br /> PROPERTY <br /> Y of Ripon Address 259 N.Wilma Avenue City Ripon Zip95366 Phone# (209)599-2108 <br /> Owne <br /> C-57 contractor EnProb Address P.O.Box 6093 ON Oroville Zip 95966 Uc#777007 Phorre4(530)5$92019 <br /> 660 Baker Street Costa Mesa . (714)662-2759 <br /> Consultant/Sub Corr ECNI res <br /> Adds City -ick Phoria# <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED; <br /> X NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH.HAND ER,OTHER*) g DESTRUCTION (atoose type below) <br /> X SOIL BORING# 2 5G•Il L S�-b1�Ib:�ta,� 0 OVER-BORE. DIAMETER <br /> - <br /> a WELL# D PRESSURE GROUT <br /> O.Other GROUT SPECIFICATIONS <br /> COMMENTS:Two geoprobe borings will be installed. Please see attached map. S!.-t 1, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA OF BOREHOLE- 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ]]STEEL g PVC O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> p AIR SPARGEI OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes B No (NOTE'MAXIMUM FREE-FALL DEPTH IS 30') <br /> X SOIL BORING g HAND AUGER GROUT SPECIFICATIONS t.Jtnl' Cv <br /> -. 11 OTHER: - D OTHER- - APPROX.BORING DEPTH 10 feet a BOLTED TRAFFIC BOX or a STOVE PIPE - <br /> CONDUCTOR CASING PROPOSED (H YES,list sperdfications in comment section) <br /> COMMENTS: Bonngs wdi 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 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�t Tige/Company Program Managers Emrironmanfal Cost Management,Inc. <br /> Prim Name Binayak Acharya Date l l La 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED::11 qt I1 t a l4I 19�' <br /> Application Accepted By d � 1/I�.rA /l.r.-.}{^ Date IssuedI 0 Z O� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDITONS, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> T�t�l 4�1•oD �q o , Wd.rm SR#00513 "k <br /> C-57-y' WC✓✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment don <br /> EHD 29-02-061 <br /> 622/04 <br />