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o,a N • San Joaquin County IRECI� V EID <br /> Environmental Health Departmenti 2006 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA4�02 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.*9M9ftT HEALTH UNIT IV <br /> `" <br /> PERMIT/SERVICES <br /> 0 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 Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. .2 Sq 140 (� <br /> 320 S.Stockton Avenue S lreet Ripon 95366 Assessors J S9t19a / <br /> WELL Location Cross Street City Zip Parcel# <br /> PRODA41t Far✓r`s all/rr,Wq.. p.Q Box 186 <br /> OwnePERTY JerryJenkins I�r1'd~n"' Irs#same as well location City Ripon Zip 95366 Phone# -5`��. 3y3s <br /> C-67 Contractor Gregg Drilling Address 950 Howe Road Road City Martinez Zip 84553 Lic#455165 Phone#(925)-3135800 <br /> Consultant I Sub Cntr ECM Address 660 Baker Street CityLic# phone# (714)662-2759 <br /> GIS Coordinates:X .Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION (choose type below) <br /> B SOIL BORING# B OVER-BORE. DIAMETER <br /> B WELL# B PRESSURE GROUT <br /> X Other S61 oas Borino 3 / 5G7/$6'8 7 GROUT SPECIFICATIONS <br /> COMMENTS: ^5 G I +b„?5/ S lv 5 & 8 S <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS <br /> B MONITORING B HOLLOW STEM DW.OF BOREHOLE B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL B PVC B OTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS B HOSE <br /> B AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes X No (NOT : MAXIMUM F/R_EE-/FALL DEPTH IS 30') <br /> X SOIL BORING BHAND AUGER GROUT SPECIFICATIONS C2./✓L Or' t7fiNSP�I <br /> BOTHER, 0 OTHER APPROX.BORING DEPTH '- V '1 S r B BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES,list specifications in comment section) <br /> COMMENTS: 13 borings will go up to 5 ft bgs and 2 up to 25 feet bgs <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 /> Signedx�Qa Anl—� Title/Company program Manager,ECM <br /> Print Name Binayak Acharya Date���/��o-�• <br /> DEPARTMENT USE ONLY n <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 y yhoL�CJ 11 t w F 1 Da <br /> WORK PLAN DATED: 5 L00 ow, 4-0 4-0 gz ,u C� tr, O3d6 S <br /> Application Accepted By I LF a--RZ+r w^' Date Issued af,I, 1 LL� IOL Area <br /> Grout Inspection By Date Final Inspection By /•u�� Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> s 2n 3779 1 SR# y-7q C.5 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-024)01 <br /> 6l2v04 <br />