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ly �D SAN JOAQUIN COUNTY • FILE COPY <br /> 2 i ENVIRONMENTAL HEALTH DEPARTMENT <br /> e. SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> c9 P Telephone:(209)468-3449 Fax.(209)468-3433 Web:wwwAclov.orG/ehd UNIT IV <br /> �I FOP <br /> WELL PERMIT APPLICATION <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 San Joaquin County Environmental Health Department. <br /> 519 S. Stockton Ave W Fourth Street 95366 Assessor's 25932025 <br /> Well Locatlon Cross Street City Ripon, CA Zip Parcel# <br /> Property <br /> Owner Nest16 USA, Inc Address 800 North Brand Blvd City Glendale, CA Zip 91203 Phone if <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lic#485165 phone 925-313-5800 <br /> Envizonmental Coat <br /> Consultant/Sub Cntr manaoemeent. inc. Address 3525 Hyland Ave,Ste 200 City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> GIS Coordinates:X 3�•TJS--- ,Y —J 2.L• IZ� ,Township 2S Range 8E Section 29 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) IN DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ®OVER-BORE DIAMETER ear sate aoamin county <br /> ❑WELL# V6 F. ®PRESSURE GROUT orainsnoe Code section 9-1115.6, <br /> [_1'OTHER F <br /> off GROUT nSPECIFICATIONS Sutseccion 6.3 <br /> COMMENTS: Well completion log attached <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS \^ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 6 `U <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL If PVC ❑ OTHER <br /> ®VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL B' TREMIE TYPE TO BE USED❑AUGERS❑HOSE 1 <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> 24 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE JJJ <br /> CONDUCTOR CASING PROPOSED (if YES,list Verifications in comment section) <br /> COMMENTS: <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations-and art annlrnahla California Laws. <br /> Title/Company <br /> Signed _ <br /> {)a-""O'g""' Project Manager, Environmental Cost Management <br /> " a'1`���- <br /> Print Name Binayak Acharya Date September 16, 2009 <br /> '\ DEP RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 236 iq ��� � <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED g 0/ AREA Qb <br /> GROUT INSPECTION BY 11 __ FINAL INI! ® DATE <br /> DESTRUCTION INSPECTION BYN6 y DATE <br /> C <br /> 1 ' ` <br /> COMMENTSICONDITIONS: \A- • er �fTWA` i`ll [�K.. OtfoFia.�At Yy G'a'3 Lw.-- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D Y TE PERMIT/SERVICE# INVOICE <br /> o w i oelr� R# <br /> C-57 W _-WAIVER C57 LETTER OF AUTHORI ION TO SIGN PERMIT vr ENCR C <br /> EHD 291 1I/6ro7(wEB) FILE C 0 P WELL PERMIT APP <br />