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WELL PERMIT APPLICATION FOkM <br /> SITE <br /> MAR 0 is 2001 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ENVIRCI�J{ti�E!`Ji HEAL" 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> PER�N!J/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 `Cm 3jl.f(y'7 <br /> WELL Location Right of way on Colony Road Cross Street Jack Tone Road City Ripon Zip 95366 Parcel#k <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 /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) pq DESTRUCTION (choose type below) <br /> 0 SOIL BORING# [X]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: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 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 301) <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 IZ Title/Company CEO/ GENESIS ,FNGINFFRIN& & REDEV. <br /> Print Name Date2VO7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ay* C <br /> WORK PLAN DATED:. r A r <br /> Application Accepted By 'Z1,j - Date Issued Area J 'S <br /> Grout Inspection ByDate 0 Final Inspection By ate 3 l9 07 <br /> Destruction Inspection 8 Date Q 7 <br /> COMMENTS/CONDITIONS: r `2 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,2go2_ GD ��• (?0 SR# 0C)+ 79 <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 9/30/02'` <br />