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oAq `"• •an Joaquin County ID _ <br /> Environmental Health Department SITr <br /> < 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 NOV 1 6 2000" !f M70N <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or�/ehd <br /> ... NVIRONMENT HEALTH UNIT 11/ <br /> ``FOS Well Permit Application PERMIT/SERVI <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 Developme-^r T4 i � mr P-1115.3 and the S ndards of S p Joaquin County Environmental Health Department. <br /> 7Clt C�(�j'(. WeS'�p• /�-a� �� Assessors <br /> WELL Location. please s�"P�-"9' _CrossS/treet" City Ripon Zip 95366 Parcel# <br /> PROPERTY City of Ripon 'S <br /> Owner Address City Ripon Zlp 95366 Phone# (209)599-2108 <br /> Boart Longyear 7773 Seldon Lane Peoria A* 85345 694686 (800)808-2420 <br /> C37 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr ECM Address 660 Baker Street City Costa Mesa-ic# phone# (714)662-2759 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> X NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> X SOIL BORING# p OVER-BORE. DIAMETER <br /> X WELL# fA 32� L yn Ll1 141 L, M Llj1� (Lt� 0 PRESSURE GROUT <br /> 0.Other M43 L) h'1 (, ()GROUT SPECIFICATIONS <br /> COMMENTS: A total of 16 wells will be installed of which some of them are cluster wells. Please see the map and table attached. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE-jQf 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: :2 <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL X�IVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Va rt e 5 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: M2XIMUMy FREEfe-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS CGMe wF bGn�0311 <br /> 0 OTHER: n OTHER-Sonic drill APPROX.BORING DEPTH Varies,see table j BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f YES,list specMcations in comment section) <br /> COMMENTS:_Please seethe work plan and table attached table for details of construction specification — <br /> Scree_n t nfi.er V0.t S 5 15 No rvW re_ tha r P- Ads+e-j W e I(S(b tyre l.o l-e- <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. /�&1l�J j5-195!3 <br /> Signedx lv� f� �. _ Titie/Company I�� m, EC� r `0 7114L40-4(873 <br /> PdntName 921rjgj4v- A C-h a*4 A- Date_ a <br /> DEPARTMENT <br /> �USE <br /> ` ONLY 'nn <br /> SITE MAP IN UNIT IV FILE,AQDR SS: IZ 30 L rLQ l VC ( pd I'1 <br /> WORK PLAN DATED: 1 L t 3 f O // Q <br /> Application Accepted By Date Issued �� oZ�( I j} (J Area ` <br /> Grout Inspection By Final Inspection By Date 91LQ6 <br /> Destruction Inspection By 0 Date <br /> COMMENTS/CONDITIONS r n 12 - ' r ovier Z0 -3 Q / <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> SR# � <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6!77!04 <br />