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• SAN JOAQUIN COUNTY • FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> til 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT <br /> WELL PERMIT APPLICATION �� v <br /> `I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x� <br /> Application 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 /> 230 Industrial Ave E Fourth Street Assessor's <br /> Wetl Location Cross Street City Ripen, CA Zip 95366 Parcel# 25938001 <br /> Property California Freight Sales <br /> Owner g Address 251 E Fourth Street City Ripon, CA Zip 95366 Phone# 209-599-5410 <br /> C-57Contractor Gregg Drilling Address 950 Howe Road City Martinez, CA Lic# 485165 Phone 925-313-5800 <br /> Environmental cost <br /> Consultant/Sub Cnfr me AddresS3525 Hyland Ave,ste 200 City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> '-Z-'- 0,455.F" �+ , 6 2091973.280 <br /> GIS Coordinates:X 'i�• 38' 13,y -I.?,,.L I]� —1-rownship ZS Range BE Section 29 <br /> �T .41I v5+5i..e <br /> WORK TO BE PERFORMED:6381863.841 2091487.141.' 6381955.884 2091470.381 <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGEROTHER-) ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# 1 ,46-1 'je-1 J6•7 IX1 ETERner OVER-BORE DIAM $an aoaenin county <br /> [I WELL# I ./b ' ®PRESSURE GROUT ordinance code Section 9-1115.6, <br /> El-OTHER GROUT SPECIFICATIONS subsection 13.17 (monitor Wella) <br /> Seven We on this parcel. Well completion logs attached; <br /> COMMENTS: A s Agreement in place with property owner and attached <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2" & 4" W <br /> El MONITORING El HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ O <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> Between 5' and 9' <br /> ®VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <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 /> Water present a ween an <br /> [MOTHER: at -29 fbqs ❑OTHER: APPROX.BORING DEPTH ter 1 ogc M BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,iist speafrations In comment section) <br /> COMMENTS:npctrny the,wpliq hy hraaking casi <br /> 1hM1g P gn f gal In)Ilino rot the c all racing in 1 hole. and than grout filling tha horehnlP If <br /> during the process of pulling out the ng,the casing Is broken, then over-drilling will be used to ensure proper destruction. <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 all applicable California Laws. <br /> Signed _ 1�iY '-�1."'a-'-- Title/Company Project Manager, Environmental Cost Management <br /> Print Name Einayak Acharya <br /> Date November 18, 2009 <br /> DEPARTMENT USE7ONLY �0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �"' '- --+/ <br /> WORK PLAN DATED: 16 - Z1- 0 / <br /> APPLICATION ACCEPTED BY _r DATE ISSUED �� ARE <br /> GROUT INSPECTION BY r '. ✓ V FINAL INSPECTION BY1 /, - DATE x'31 j <br /> I 1 _ <br /> DESTRUCTION INSPECTION BY MIw DATE �`LI.L'F�"51.b� 1 _ <br /> COMMENTSICONDITIONS: VIC-- WIII erw1Nft� troe,\_F� �A4- �0 (.104AX- D�MiG LW �v 54UAOV <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> a01� /50 �o e9 SR# 7 /U <br /> C-57 y WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT gCy{MFyT� IT A <br /> EHD2Ml 11/5/07(WEB) A 1 E ,jV■•I'iH/` <br />