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San Joaquin County <br /> 06` Environmental Health DepartmenlW D SITE <br /> 304 East Weber Avenue. 3rd Floor, Stockton CA 95202 DATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or&941L j 7 2006 UNIT IV <br /> \c\iFaa"P Well Permit Application ENVIRONMENT HEALTH <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1ssu&RMIT/SERVICES <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 So <br /> _Joaquin County Environmental Health Department. G q <br /> WELL Location 212 S.Stockton Avenue Cross Street ftarrrnSbeet City Ripon Zip 95366 Asses:ce��g-a !o-a / <br /> PROPERTY David Van Vliet same as well location Ripon 95366 <br /> Owner Address Ciy Zip Phone# <br /> Cal Contractor Gregg Drilling Address 950 Howe Road Road cay Martinez Zip 94553 Lic#455165 Phone#(925)-3135800 <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 /> B NEW WELL f BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) B DESTRUCTION (choose 4"below) <br /> B SOIL BORING# n OVER-BORE. DIAMETER <br /> B WELL#_ B PRESSURE GROUT <br /> X*Other Soil cas Borina GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING B HOLLOW STEM DIA.OF BOREHOLE r B MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> B EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: B STEEL B PVC []OTHER:_ <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: B AUGERS B HOSE <br /> B AIR SPARGE!OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: B Yes X No (NOTLp MAX�LMUMIF�REE-(FALL DEPTH IS 30') <br /> X SOIL BORING B HAND AUGER GROUT SPECIFICATIONS C Y�Ty�2v� O� J� PMTo n T" <br /> B OTHER: R OTHER APPROX.BORING DEPTH S f 0 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 /> Signed><�Df 'Lyp it=I2 Tide/Company Program Manager,E�C,M/��` <br /> Print Name INnayak Acharya Date / /(Y'./a'6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: t a <br /> WORK PLAN D&FEB C 4 <br /> Application Accepted By Aa4r ' _`--"' Date Issued -711110 (a Area <br /> Grout Inspection By Date Final Inspection By Date -7 T <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 /> 37?2 1 SR# L4)563 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-WI <br /> 6/22'04 <br />