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WELW ERMIT APPLICATION WM 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 for a permit to construct and/or 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 138 Parallel Avenue Cross StreetAssessors <br /> City Ripon Zp 95366 Parcel# 261-150-06 <br /> PROPERTYOwner Ed Bynum Address 138 Parall 1 AyCityRinnn Zip-1S-3.6.fiPhone# (209) 9-4 <br /> X2,337 <br /> C-57 Contractor Spectrum Explorati"%gresslnc. 2365 Wiewam Dr�ityStocktonzi <br /> P-25=LicA5l 68 Phone#(9�9) X65-8712 <br /> Consultant/Sub Contractor ERM West Address1809 N. Helm Ave.QtyFresno Lia* Phone# (559)452-8010 <br /> GIS Coordinates:X Y Township T.2S. Range R.8E. <br /> 9 Section 29 <br /> WORK TO BE PERFORMED <br /> NEW WELL/BORING(CPT, GEOPROBE. HYOROPUNCH. HAND-AUGER.OTHER-) 0 DESTRUCTION(choose <br /> 0 SOIL BORING# type below) <br /> WELL* M_-5C1 and M- 2 9OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 10n-F MULTIPLE CASINGS?Ii YES" NO WELLCASING OIA: <br /> a <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSsched. 80rypE OF CASING: 0 STEEL 3ft PVC p OTHER: <br /> Q VAPOR M MUD ROTARY DEPTH OF GROUT SEALsee commentlFiZEMIE TYPE TO BE USED: <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: GAUGERS IGHOSES 301 PVCpip <br /> (Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX. BORING DEPTH 200' TBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 OTHER: p OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: The bentonite grout seal will be from 0 to 138 feet below gracip and , 152 tn ISS re <br /> below grade or 2 feet above and below screened intervals. t <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 in accordance with 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: '7 certify that in the performance of the work <br /> for which this permit is issued,t shall not employ persons subject to WORKERS'COMPENSA PON Laws of California.- Contractors hiring or sub- <br /> contracting si nature certifies the following: 'i certify that in the peAonnance of the work br wniGl this permit is issued. l shall employ persons subject to <br /> WOR 'C PENSATION Laws of California." <br /> THE APPLICANT U T CALL 48 HRS IN ADVANC FOR ALL REQUIRED INSPECTIONS. <br /> c <br /> Signed x / <br /> Title O"t. —0ate �D /d 9 <br /> SEE SITE MAP UNIT IV WORK PLAN DATED <br /> DEPARTMENT USE ONLY M` <br /> Application Accepted By I IM,(VI1rvJ 'hh,,., S Date Issued lu-t p1• pP�-gtaa�D <br /> Grout Inspection By �-- Date Final Inspection By <br /> Destruction Inspection By Date 0 ttg� <br /> COMMENTS/CONDITIONS: <br /> WN C GES ON <br /> SPN �NEA� 1EPEtN <br /> ACCOUNTING ONLY: AID# i FAC# EN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#t ASH RECEIVED BY I DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> C-57 LICENSED CONTRACTOR MUST SIGN LICENSE&WORKERS' COMPENSATION DEC ATION <br /> UNIT IV- 6/23/99/sion bkoo/MI <br />