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San Joaquin County — <br /> � �` Environmental Health Department SITE <br /> s 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449Fax:(209)468-3433 Web:wwwsjgov.org/ehd UNIT IV <br /> ME���ES <br /> Well Permit Application <br /> EN`nDR MISER NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Appllrallort�hereby made to San Joaquin Caariyy for a penult to construct and/or install the work described. This application is made in compliance wAtn San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ;rF Assessors 25929004 <br /> WELL Location PB6�Industdai Avenue Cross Sheet 4th Street City Ripon Zip 96366 Parcel# <br /> PROPERTY California Freight Sales Address P.O.Box 365 City Ripon Dp 95368 Phone# <br /> Owne <br /> C-57 Conhactor <br /> EnProb Address P.O.Box 6093 Cm,Oroviile ZIp 96966 777007 phon (530)589-2019 <br /> ECM Baker Street,Ste 253C Costa Mesa (714)662-2759 <br /> Consultant/Sub Cntr Addms$W rty Jc# Phone# <br /> GIS Coordinates:X Y ,Towre* Range Section <br /> WORK TO BE PERFORMED' <br /> X NEW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER? 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# n 0 OVER-BORE. DIAMETER <br /> - <br /> X WEU-* 1 P$(=�,1 <' p'wQ J - UPRESSURE GROUT <br /> o oothar - GROUT SPECIFICATIONS <br /> COMMENTS:One Soil vapor monitoring well to 5 feet below ground surface will be installed. Please see attached map. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOLE 7 0 MULTIPLE CASINGS 0 MULTI-LEVEL YVELL CASING DIA: 1 - <br /> a EXTRACTION 0 AAR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL X PVC 0 OTHER: <br /> )S VAPOR(monitoring) a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> _ __ <br /> - -- a RIRSPARGEI OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING X HAND AUGER GROUT SPECIFICATAONS <br /> 0 OTHER: R OTHER APPROX.BORING DEPTH-E2!-----X BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances,R�ulesp and Regulations,and all applicable California State Laws. <br /> (1 ^ ,� !]. ,( --�y� ram Manager/Fsvironmental Cost MAana9amant,Inc. <br /> Signed x-��-�L—'L-"-'�'-,� TiaelComparry�9 <br /> Print Name Binayak Acharyo Date <br /> DEPARTMENT' USE/ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: Z'Sa - <br /> WORK PLAN DATED: (" �Alok 1.71 0-t. - <br /> Application Accepted Sy ytnt >•1 ^rte I' Date Issued - Area <br /> Grout Inspection By l Date Final Inspection By Date L1 T- d1' <br /> Destruction Inspection By Date <br /> COMMENTS]CONDITIONS: <br /> ACCOUNTING ONLY: AID# ppm!. <br /> PECODES FEE INFO AMOUNTREMITTED CHECK# RECD BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -01VL 70 X0 � SFW voS��oC <br /> C-57_Z WC_�/-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> EHD29- 2 l <br /> 6/22/04 <br />