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I s ?- �o SAN JOAQUIN COUNTY � ENVIRONMENTAL HEALTH DEPARTMENT LOP " SITE MITIGATION t.' 600 East Main Street, Stockton, CA 95202-3029 Telephone, (209) 468-3454 Fax: (209) 468-3433 Web:w".siaov.org/eh UNIT IV RCf�OR � WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �� I 1 y�1�Z Site Locatioty Hwy 99 — Front Brady Lane City Ripon Zip 95366 APN - -2 1 Property Cit of Ripon on 259 N Wilma Aire Owner y p Address City Ripon Zip 9 5 3 6 6 phone 553-2108 C-57 Contractore an onm Address9241BeattyDr sultACity Sacr. Lic 848359 Phone 916-353-9355 Consultant/SubCntr AGE Address 837 Shaw RoadCity Stockton Lic 95219 Phone 467-1006 Billable Party Ripon Farm SerVAddress 405 West Pine' St City Lo Zip 95240 Pho30-963-4090 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) [],SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLlBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �❑ MONITORING ©HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA —[I EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑I'VE _❑SOIL BORING ❑PUSH POINT(GP!CPT) GROUT SEAL PUMPED',❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i-e.krSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland ` _❑OTHER', ❑OTHER APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:- Boring Dia: COMMENTS: NOTE: OFFSITE WELLS Sr BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELL}rS)TO DESTROY OVER-BORE DIAMETER OF W CHES TO DEPTH OF 3 F7 WELL IDS. MW we"ll S : O E-site ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE Xr GROUT SPECIFICATIONS ® }1Hi q ❑EXPLOSIVES FROOM TO FT BELOW SURFACETREMIE p COMMENTS E TO BE Work pian l an GcLatee 01 J my 2 01-1; a r❑ova)HRdateOM Ad p0�3 NOve eY FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS . W hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and plicable Ca' is laws. Signed �M � Title/Company Geo l og.i S t / AGE fn PrintName . William Little Date 12/28/2011,..___.. DEPARTMENT USE ONLY s SITE MAP IN UNIT IV FILE-SITEADDRESS 93Z. t- + J s^� WORK PLAN DATED Cb APPLICATION ACCEPTED BY . DATE'Vlk ' --AREA l. I S 9 E GROUT INSPECTION BY FINAL INSPECTION BY -=LATEZ�`Z DESTRUCTION INSPECTION BY DATE •l �r�aa11 COMMENTSICONDITIONS: je ACCOUNTING ONLY: AID# FAC# `n PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY RATE SERVICE RO# INVOICE v' REQUEST PR# .� 4 - z $ 12 x Z .2 570. 0 0 :34-z 57 0 _ 7 ► 1: SR# 00 6 42 G.0 � 50 3 S Roo. 3 Gz 5. 00 iso C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ E HD 29-D1 07128110 WELL PERMIT APP "