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o �� tan Joaquin County *REM <br /> / `aEnvironmental Health Department <br /> E <br /> 304 East Weber Avenue, 3rd Floor. Stockton,CA 95202 JUL 1 71 tTAGATION <br /> \• (209)468-3449 Fac: (209)468-3433 Web: ivww.sjgov.org/ehd UNIT IV <br /> ENVIRONMENT HEALTH <br /> e'UFoa�P Well Permit Application PERMIT/SEHVICES <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 applicafion is made in compliance with San <br /> Joaquin County Development TRH Chapter 9-1115.3 and the Stand ds of San Joaquin County Environmental Health Departmentcl 3 20._ 0 <br /> 230 Industrial Avenue 7 f� <br /> Assessors <br /> WELL Location `r-3' v Cross Street i �' City Ripon Zip 95366 parcel# 2S�1. 3Btu'" <br /> PROPERTY David Sanders same as well location Ripon <br /> Owner Owner Address City Zip Phone# <br /> Cbl Contractor Gregg Drilling Address 950 Howe Road Road City Martinez Zip 94553 Lic#455165 Phone#(925) 13-5800 <br /> Consultant/Sub Cntr ECM Address 660 Baker Street City Lic# Phone# (714)662-2759 <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [IDESTRUCTION (choose type below) <br /> 0 SOIL BORING# I]OVER-BORE. DIAMETER <br /> a WELL#_ a PRESSURE GROUT <br /> X*Other Soil Qa5 BorinO SCnq -1 - lY I GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLEWr B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS B HOSE <br /> a AIR SPARGE/OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes X No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .-� <br /> X SOIL BORING aHAND AUGER GROUT SPECIFICATIONS ra-r +''�'1 ar b�-�on,'�--e-- <br /> 0 OTHER: fl OTHER APPROX BORING DEPTH S t BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 13 borings will go up to 5 ft bgs and 2 up to 25 feet legs <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 ���` -- TNe/Company Program Manager,ECM <br /> Print Name Blnayak Acharya Date 7����� <br /> J= <br /> DEPARTMENT USE ONLY n� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: —:-L 3-0 r\ 1.4-s+'10. I IC t 12A ✓,, <br /> WORK PLAN Vic_ �S CAID -1-0 L 0 W &- L,6 ()<J-'266 G7 <br /> Application Accepted By I ' I - .t6�1�'L7 Date Issued Z 6 Area [ It f 11 <br /> Grout Inspection By Date Final Inspection BY-73A. Date 0 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a`t o . 4j S I '1 3?79 SR# L{'1 S ba <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-W 1 <br /> 6/72104 <br />