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I1 IL-k-jC1 V'"_'u °PaurN' ° SAN JOAQUIN COUNTY �� �.•'�E'•.o JAN 2 7 2- ' N IRONMENTAL HEALTH DEPARTMENT LOP EtVV1RONMENTALHjst Main Street, Stockton, CA 95202-3029 SITE MITIGATION -f*@h%TJ85R 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV Q�rFOR ` 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. Site Location 9 32 S Hwy 9 9 Cross Street Brady Lane City Ripon zip 953 66 APN 261-02-011 Property Ripon Farm Servic 405 West Pine St 95240 Owner p Address City Lodi zip Phone 630-963-4090 C,J C-57 Contractor AGF Address 837 Shaw Road City Stockton Lic 95215 Phone 467-1006 Consuftantlsub4nhPe an onmAtddatty r Suress ei City Sacr. 1-048359 phone 16-363-9355 BiflableParty Ripon Farm ServAddress 405 West Pine St City ° 1 zip 95240 Ph,&30-963-4090 ft1 GIS Coordinates:X Y - CONSTRUCTION WORK TO BE PERFORMED: FILE GOPY ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs �- ❑OTHER IDs TYPE 8 #OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DA: _❑EXTRACTION:Vapor!Water ❑HAMMEMDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(iaAir Snerae.Ozore)❑HAND AUGER GROUT SPECIFICATIONS Portland _❑OTHER ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PfPE r n CONDUCTOR CASING❑No❑Yes Casing Dia: Casing Depth: Boring Dia.- COMMENTS: iaCOMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHEc L HAT APPLY 2-7 gggg m -#OF W�,I,��S)T DESTRaE OVER-BORE DIAMETER OF INCHES TO DEPTH OF' T 1'27 IL WELL IDs:WW W S an V W wells ❑PRESSURE GROUT TO DEPTH OF FT BFZOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:IN AUG�RS K) OSE (PIPE F]MUITRQOM CAP AT >>3 FT) FT BELOW SURFACE COMMENTS Work plan ateCCii 01 my 2011; approval dated 07 Noveffiber 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and 44 Regulations,and of plicabl ornia taws. Signed Title/Company Geologist / AGE Print Name William Little Date 12_f 28/2011 DEP / DEPARTMENT USE ONLY G �J SITE MAP IN UNIT IV FILE-SITE ADDRESS Q 3 F.. F1.0n+-dd a 'Rd- S. N i alr d v ,[,q,___ _- WORK PLAN DATED J 20 1 APPLICATION ACCEPTED BY i'YZ DATE I EA 145-1 GROUT INSPECTION BY FINAL INSPECTION BY w�---- TE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: Sf,- i -I-'>75W7tp 5 ( ? I-A :-L� � of -4 Vw 1j ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 50;L $ 121 .7 S . UU 342$ D VK 112-7//2-- SR# 425 R S0 375.00 375. 00 o0 3 1� 0� PR# _ 2900 C-57 WC WAIVER _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ EHD 29-01 07/28110 WELL PERMIT APP