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- ' SAN JOAQUIN COUNTY � �� <br /> ?` ENVIRONMENTAL HEALTH DEPARTMENT l r. SITE <br /> . ''SN. 0 4 2010 <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> r .P� Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:WWW.si gy.Qr IMENT HOIAWt IV <br /> \Q�1F ORt1/ <br /> WELL PERMIT APPLICATION PERMrjj <br /> r �t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED It <br /> Application is hereby made to Sen 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 /> Assessors <br /> Well Location 1501 N.Jack Tone Road Cross Street Santos Avenue City Ripon Zip 95366 parcel# 22811017 <br /> Property <br /> Owner Flying J. Inc. Address 333 W.Center Street City N.Salt Lake zip 84054 Phone# (801)624-1434 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# (925)313-580(�hone <br /> ConsultanttSub Cntr Kadence Consultants Address 2800 IN Parham Rd.Ste 100 City Richmond Lic#23294 Phone (281)435-665.8__ <br /> GIS Coordinates:X 37"45'22.08"N Y 121"8'39.63"W Township 2S Range7E Section 13 <br /> WORK TO BE PERFORMED: <br /> [5�NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# SB-1 and SB-2 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT _ <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> 1 <br /> COMMENTS: r n <br /> v 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> r-1MONITORING !XI HOLLOW STEM DIA.OF BOREHOLE 5 112 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DER: Q <br /> ❑EXTRACTION ❑AIR HAM MER/DR IVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ` <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 25 Feet TREMIE TYPE TO BE USED®AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes P(No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30' <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER. ❑OTHER APPROX.BORING DEPTH 25 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE (✓ <br /> CONDUCTOR CPSING PROPOSED (+3 YES.I'St spacllcations�rnninent section} F <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS r` <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify t t I ve prepared this application and that the work will be done I accordance with San.Joaquin County Ordinances,Rules and <br /> Regulations, all pl' ble alifornia Laws. <br /> Signed n Title/Company Principal/Kadence Consultants,Inc. _ <br /> Print Name Kenneth R. Earnest Date ✓f U� �� <br /> DEPARTMENT USE ONLY <br /> — <br /> SITE MAP IN UNIT IV FILE,ADDRESS, I_ d <br /> WORK PLAN DATED C�C.+bjo ew 2 x 0 9 <br /> APPLICATION ACCEPTED}BAY 1/;C.+o r�1a M r-(fa r+n e ( DATE ISSUED 1 - 12—j & <br /> 1 AREA l45 <br /> GROUT INSPECTION BY Y 1 c 4 I�Z!!� <br /> �IYAI t� FINAL INSPECTION BYy j Q ` 1 'b.47gs-11 DATE <br /> DESTRUCTION INSPECTION BY JJ--DATE <br /> COMMENTSICONDITIONS: i 0 ri no.$ +p .2 S 1 ace, <br /> ACCOUNTINGONLY_ _ AID# FAC# _ <br /> PE CODES EE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3503 34� 5'.00 434 00 12 - 16 SR#0059 3L <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10f28M WEi L PERMIT APP <br />