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ul San Joaquin County ° lmw <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton.CA95202JUL 1 7 2006 MITIGATION <br /> r (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.or ehd UNIT IV <br /> ENVIRONMENT HEALTH <br /> ,FOR Well Permit Application PERMIT/SERVICE <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 Se Joaquin County Environmental Health Department. <br /> 206 S.Stockton Avenue F-A�e Street Ripon 95366 Assessors q 2-q o a o <br /> WELL Location Cross Street City Zip Parma# L� <br /> PROPERTY American Legion Hall same as well location Ripon 95366 <br /> Owner Address City Zip Phone# <br /> C-67 Contractor Gregg Drilling Address 950 Howe C ty Martinez Zip 94J83 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 /> U NEW W ELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# DOVER-BORE. DIAMETER <br /> 0 WELL#- a PRESSURE GROUT <br /> X*Other Sal oas Borina _ C� ,5&3 GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> B MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE/ B MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a.AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O PVC a OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> a AIR SPARGE/OZONE X PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes X No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> X SOIL BORING aHAND AUGER GROUT SPECIFICATIONS L- Br be—'+-D fN, { L_ <br /> a OTHER: n OTHER APPROX.BORING DEPTH S a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES,list specifications in comment section) <br /> COMMENTS: 13 borings will go up to 5 ft has and 2 up to 2.5 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 /> Program Manager,ECM <br /> Signed x //1J1� Title/Company <br /> Print Name Bmayak Acharya Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:—1 0-30 `CY�KSfI rT 0A , <br /> WORK PLAN Q469W St.�Y9✓ -rte C Q W-4A)0,L46 <br /> Application Accepted By non I' � Date Issued I 11 D G Arreea'�9�l-zZ <br /> Grout Inspection By Date Final Inspection By ",tjL ate I 1 / Vli <br /> Destruction Inspection By Date <br /> COMMENTS J CONDMNS: <br /> ACCOUNTING ONLY,' AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST if INVOICE <br /> SR# t4'756 j <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EEID 29-02-001 <br /> 6122,'04 <br />