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San Joaquin County fillno <br /> IECE <br /> o .. ..., �o <br /> Environmental Health Department ITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> t'•., % (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehdJUL 1 7 2006 UNIT IV <br /> \� F.0' Well Permit Application ENVIRONMENT 1 jEAffH — <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/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 SarVloaquin County Environmental Health Department. <br /> *Mat tY Assessors T;� <br /> WELL Location 210 S.Stockton Avenue Cross Street FrStreat City Ripon Zip 95366 Parcel# 2q U <br /> PROPERTY Darryl Bartels same as well location Ripon 95366 <br /> Owner Address City Zip Phone# <br /> G47 Contractor Gregg Drilling Address 950 Howe Road Road City Martinez Zip 94553 UaC 455165 Phone#(925)3135800 <br /> Consultant/Sub Cntr ECM Address 660 Baker Street City Lid# Phone# (714)662-2759 <br /> CIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL#- a PRESSURE GROUT <br /> X•Other. Sal aas Borina S GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u MONITORING a HOLLOW STEM DIA.OF BOREHOLE' a MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [[AUGERS a HOSE <br /> a AIR SPARGE]OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: aYes XNo (NOTE- MAXIMUMFREE-FALL DEPTH IS 30') <br /> XSOIL BORING aHAND AUGER GROUT SPECIFICATIONS CC� D � .b LJvn,� z- <br /> 1]OTHER: n OTHER APPROX.BORING DEPTH 5-1 a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (A 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 z �.� Title/Company Program Manager, ECM <br /> Print Name Binayak Acharya Date - j� /' b 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : <br /> WORK PLAN VATM: <br /> Application Accepted By. Date Issued 0 Area / Z <br /> Grout Inspection By Date Final Inspection By Date 7 �- <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 1 4 '31 3?-7er- I jSR# y-t spy <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22'44 <br />