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• p N` 5/A• SAN JOAQUIN COUNTY • FILE COPY <br /> oq <br /> el ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> N p/ Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION ON �, <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 /> 230 Industrial E Fourth Street Assessor's <br /> Well Location Cross Street L City Ripon, CA Zip 95366 parcel# 25938001 <br /> PropOwnertyX_„- .�L ,�le "Address Address/-V�YQS City Zip 95366 Phone# <br /> Owner l/YV7 cJL��iy Ripon, CA 209-599-5418 <br /> C-57 Contractor Gregg Drilling Address 950 Howe RoadCity Lic# Phone Martinez, CA 485165 925-313-5800 <br /> Environmental cost <br /> Consultant/Sub Cntr Man.Qemenc. ,nt. AddresS3525 Ryland Ave,Ste 200 Cit, Costa Mesa .Lic#778024 Phone 714-662-2759 <br /> GIS Coordinates:X 31' 1* ,Y '91. 17-7/ ,Township ZS Range BE Section 29 <br /> 6381685.32 2091061.59 <br /> WORK TO BE PERFORMED: <br /> M NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> E WELL# M-50A and M-51A ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Two wells to be installed, per Central Valley RWOCB-approved Work Plan Access agreement attached; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $]MONITORING 91 HOLLOW STEM DIA.OF BOREHOLE 4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 M <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING:❑STEEL KI PVC ❑ OTHER 1 <br /> 2' above <br /> []VAPOR ❑MUD ROTARY DEPTH OF GROUT SE TREMIE TYPE TO BE USEDXAUGERS HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMP D 7Y.aNO.(,NOTE:MAXIMUM FREE-F//AL__L DEP IS 30')❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIO ote and cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Both to 70 feet ZI BOLTED TRAFFIC BOX OR!❑"STOVE PIPE <br /> CONDUCTOR CASINGPROPOSED If YES,list pecdi lions in mmenl c' nJ <br /> COMMENTS: <br /> NOTE: OF SITE BORINGS REQUIRE ACCESS AG EEMENT 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. 11 <br /> Signed _ �-irv. +{kms Title/Company Project Manager, Environmental Cost Management <br /> Print Name Einayak Acharya Date November 16, 2009 <br /> yy <br /> D&2ARTMENT USE ONLY ZR6 a <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J q� li✓Ielf��K� <br /> WORK PLAN DATED: el IIQ <br /> APPLICATION ACCEPTED BY DATE SUED 'Q/ AREA 06 <br /> GROUT INSPECTION BY wn, FINAL INSPECTION BY DATE At� 91 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CO N DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED JCHECK# RECV'D BY DAT PERMIT/SERVICE# INVOICE <br /> o !S!! Co ! #05?F 3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT POC_4,e _ <br /> EHD29-0111/5/07(WEB) WELL PERMIT APP/4: <br />