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G!A SAN JOAQUIN COUNTY a <br /> f_ D <br /> ENVIRONMENTAL HEALTH DEPARTMENT`�� •x' SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sicloy.o[g/ UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V <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 /> Assessor's <br /> Well Location230 Industi ial Cross Street E Fourth Street City Ripon, CA Zip 95366 Parcel# 25938001 <br /> Property - , <br /> Owner /hL Address 00 City Ripon, CA Zip 95366 Phone# 209-599-5418 <br /> Gregg Drilling 950 Howe Road Martinez, CA 485165 925-313-5800 <br /> C-57 Contractor Address CityMartinez, # Phone <br /> tnvi romnental Cost <br /> Consultant/Sub CntrMagem�e[rrt, 1��. Address3/525 Hyland Ave,Ste 200 City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> GIS Coordinates:X 31•17V Y ' (. Z!/ Township 2S Range 8E Section 29 <br /> 6381685.32 2091061.59 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> M WELL# M-50A and M-51A ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Two wells to be installed, per Central Valley RW CB-approved Work Plan. Access agreement attached; 1, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> KI MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING:❑STEEL KI PVC ❑ OTHER <br /> 2' above <br /> []VAPOR ❑MUD ROTARY DEPTH OF GROUT SE TREMIE TYPE TO BE USED/<AUGERS HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMP D Yes No (NOTE:MAXIMUM FREE-FALL DEP IS 30') - <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIO bentonite and cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Both to 70 feet ®BOLTED TRAFFIC BOX OR [:]STOVEPIPE <br /> CONDUCTOR CASING ROPO D (if YES,list pecifi tions in mment c n) <br /> COMMENTS: V <br /> NOTE: OF SITE BORINGS REQUIRE ACCESS AEMENT 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 _ 4ti�� '�5`- Title/Company Project Manager, Environmental Cost Management <br /> Print Name Binayak Acharya Date November 16, 2009 <br /> �f <br /> DEPARTMENT USE ONLY z?,,6 0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: v O li�/P.LfIeCC <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED //'3d-O/ AREA LM <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE/ PERMIT/SERVICE# I INVOICE <br /> o 15!! #05 ?1531 <br /> C-57 V WC y -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNERMIT � t]OC _ <br /> EHD 29-01 11/5107(WEB) WELL PERMIT APPA <br />