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WELIrERMIT APPLICATION F&M UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)'468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit to construct ancVar install the work described. This application is made in compliance with <br /> San Joaquin County Development Title. Chapter 9.1115.3 and the Standards of San Joaquin County Public Health Services. Environmental Health Division. <br /> WELL Location Orange Avenue right ofCmWS�et 2nd StreetCi Ripon 95366 Assessors125'S.2nd center <br /> ty UP Parcel# ?Sr4�.&e cents <br /> PROPERTY owner City of Ripon Address 259 N. Wilma Ripon 95366 <br /> C'nf Zip Phone#_(209)599-2108 <br /> C-57 Contracto$Pectrum Exploratic dreanc. 2365 Wigwam Dr. City Stockto95205Li 51226§hone# (209)465-8712 <br /> Consultant/Sub Contractor ERM West Address 1809 N. Helm City Fresno Phone# (559)452-8010 <br /> GIS Coordinates:X Y Township T.2S. Range R.8E. Section 30 <br /> WORK TO BE PERFORMED <br /> [KNEW WELL/BORING(CPT, GEOPROBE. HYDROPUNCH,HAND-AUGER.OTHER•) <br /> SOIL BORIN # 0 OESTRUCTION(choose type below) <br /> WELL#M-2813 - , - D OVER-BORE <br /> - 'Other <br /> COMMENTS: 0 PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [kIMONITORING 0 HOLLOW STEM DIA. OF BOREHOLE '� '} _MULTIP!E CASINGS? YES 2" <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSsched. 80 TYPE OF CASING:a STEL O NELL CASING DIA:__ <br /> VAPOR �t7 0 iPVC 0 OTHER: <br /> 0 AIR SPARGE a CMUD ROTARY DEPTH OF GROUT SEAL see commenVREMIE TYPE TO BE USED: Q AUGERS allOSEPVCpipe <br /> 0 PUSH POINT GROUT SEAL PUMPED: ot Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH 1601 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER:_g OTHER CONDUCTOR CASING PROPOSED? f YES, iLSt specifications here): <br /> COMMENTS: al will be to a depth of 2' above and below the --r`­e-en-e-d-1-n-E-er­V­a-rs-.- <br /> ApprnZimatg <br /> . <br /> Greened intervals are: 140-150' , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done inaccordance wnh San Joaquin County Ordinances. State Laws. and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued, I shall not employ persons subject to WORKERS'COMPENSATION Laws of Califomfa." Contractor's hiring or sub- <br /> contracting signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, /shall employ persons subject to <br /> WOR MPENSAT/ON Laws of California." <br /> THE APP IC NT MUST CALL 48 HRS IN ADVANCQI7AOR ALL REQUIRED INSPECTIONS <br /> . <br /> Signed L/�v Title /`D�/brf Date 0//,9700 <br /> SEE SITE M P IN UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 5 &AA&h) ( L <br /> Date Issued (11- 16.Oa P��t`l 1vE0 <br /> Grout Inspection By Date <br /> Destruction Inspection By sinal Inspection By <br /> Date__ <br /> Date � <br /> COMMENTS -��--�— <br /> /CONDITIONS: <br /> WN NC1V�51�N <br /> SPN gHFP NEPA <br /> ACCOUNTING ONLY: AID# FACS ENV <br /> I � <br /> PE CODES FEE INFO AMOUNT REMITTED HECK CASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C-57 LICENS CONTRACTOR MUST SIGN LICENSE &WORKERS' COMPEL-ISATION DECL 1RITION <br /> UNIT IV- 6/23/99/sign bkpg/MI <br />