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SAN JOAQUIN COUNTY <br /> CDPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sidov.org/ehd UNIT IV <br /> M• WELL PERMIT APPLICATION D/�' <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 /> Joaquip C�nty Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. R <br /> ??,, Assessor's <br /> WeiQt <br /> cation ZZJ Cross Street Stockton Avenue City Ripon, CA Zip 95366 Parcel# Stree , N/A <br /> Pro rty 209-599-2108 <br /> Owner City of Ripon Address 259 N. Wilma City Ripon, CA Zip 95366 Phone# <br /> Boart Lon ear 1333 West 9th Street Upland, CA 6 909-946-1605 <br /> C-57 Contractor gy Address City p Lic# Phone <br /> �'•,vironmental Cost <br /> ConsultanUSubCntrMa„avemer,L, r Address 3525 Hyland Ave,sce zoo City Costa Mesa Lic#778024 Phone 714-662-2759 <br /> GIS Coordinates:X 6380892 . 9 y 2089970.44 Township 2S Range 8E Section 29 <br /> -i 2t.1 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) E]DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# M-54C ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS:One well to be installed, per Central Valley RWQCB-approved Work Plan. Encroachment Permit Attached. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑ 1 2" <br /> HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: V <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Schedule 40 TYPE OF CASING:❑STEEL I&]PVC ❑ OTHER <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:L]Yes C]No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING El HAND AUGER GROUT SPECIFICATIONS✓#entonite and cement <br /> ❑OTHER: ®OTHER: Sonic rig APPROX.BORING DEPTH 165 feet KI BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS V <br /> I hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations.and all anolicable California Laws. <br /> Signed _ t � y� l_�, `. Title/Company Project Manager, Environmental Cost Management <br /> Print Name Binayak Acharya Date November 16, 2009 <br /> D PARTMENT USE ONLY ?If.V/on�l��/.� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED IZ y ey AREAQfa <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 DATY PERMIT/SERVICE# INVOICE <br /> 2401 15 It Alt R# <br /> C 57=WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNIPE MIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) 3, L ERMIT APP <br />