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PID, <br /> EC�-,! <br /> 'C "I"Il�1��'L��LL)) - <br /> WELL -RMIT APPLICATION FORM SITE <br /> 100, 0 2007 � SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRGNf�1E!'�i f? EAL(H 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> pER!z,!11T/SERVICES (209) 468-3449 <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 /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors `Lm 3 (,10'7 <br /> WELL Location Right of way on Colony Road Cross Street Jack Tone Road City Ripon Zip 95366 Parcek#z � <br /> PROPERTY Owner City of Ripon Address 259 N Wilma Ave City Ripon Zip 95366 Phone# 209-599 2108 <br /> C-57 Contractor Test America Address 3195 Luyan Dr City Ranch Cordova Zip 95742 Lic# 819548 Phone# 916-638-5564 <br /> Consultant/Sub Cntr Genesis Eng&Redev Address 351 Ruess Road City Ripon Lic# Phone# 209-251-9092 <br /> GIS Coordinates:X_663691 ,Y 418039 ,Township 25 Range 8E Section 18 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') pq DESTRUCTION (choose type below) <br /> 0 SOIL BORING# Pq OVER-BORE. DIAMETER 8- <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS Tremi:grout(Portland/bentonite <br /> mixture <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 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. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company CEO�I -�ENES►S E(VCIPIEFRINC� $� DEV. <br /> Date 2/22/03 <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_. �_ n <br /> WORK PLAN DATED: F r ut a r <br /> Application Accepted B '�/ �m�' ^ r 2Z:C4 Date Issued ,� 6 7 Area S <br /> Pp P Y�tar4l�u��/fir-��—\-� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: r <br /> ACCOUNTING ONLY: AID# FAC-1# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .� 102 Ge 3�°.� C�� � � - �li�lo SR# <br /> C-57 WC AIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02'''`i <br />