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aA4�•". �o 'tan Joaquin County • <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> { . P (209) 468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> t Well Permit Application <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 Dever`r ,,phapter 921;15.3 and the Standards of San Joaquin County Environmentaf Health Department. <br /> e st Ds'c aU .'ia Assessors <br /> WELL Location. please see the map _Cross Street City Ripon Zip 95366 Parcel# <br /> PROPERTY City of Ripon Various,see map Ripon 95366 (209)599-2108 <br /> Owner Address City Zip Phone# <br /> Cbl Contractor Address City <br /> Boart Longyear 7773 Seldon Lane Peoria Zip LidE 85345 694686 Phone# (800)808-2420 <br /> Consultant/Sub Cntr ECM Address 660 Baker Street City Costa Mesa ic# phone# (714)662-2759 <br /> GIs Coordinates:XiY ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> X NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> X SOIL BORING# Q OVER-BORE. DIAMETER <br /> X WELL# tnM US Cu I Lr) 0PRESSURE GROUT <br /> Q'Other IGROUT 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 Q HOLLOW STEM DIA.OF BOREHOLE10 Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: �t <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL ),PVC BOTHER:- <br /> 11 <br /> OTHER:Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL VArtt- S TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE:: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONS C-C'm&,— � 6x"' nITCA <br /> Q OTHER: R OTHER-Sonic drill APPROX.BORING DEPTH Varies,see table j BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (6 YES,list specifications in comment section) <br /> COMMENTS:_Please see the work plan and table attached table for details of construction speciii ation <br /> 5cratn �r� 1ova�s 5`�LS` tA0 ry_0t-e -t-Ho.-.�, 7� t�es-tCALA)*-Its te. <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 0 t.v AvL�x' _ Title/Company �'d"'- +�.. M a-+`an,s,� Er M <br /> I <br /> Print Name R,1NAyfl x— A 0i1 AfZy Q-. � Date�IT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��u D mrd tt s-� t �a ILt toOV� <br /> WORK PLAN DATED:: 103 D So p <br /> Application Accepted By / L -7 Date Issued o,d Area <br /> y- <br /> Grout Inspection By I'-r2WvK P.n r Date / Final Inspection By Date_�t/0 7 <br /> Destruction Inspection By Date <br /> COMMENTS[CONDITIONS: it �.t i2D! A-0� � fDF e .7j1�-a.d0/ E'i-tN7 aDa r-39 d / <br /> ACCOUNTING ONLY: A]D# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> On <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-ODI <br /> 61Z21O4 <br />