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oq.5'l�!IlY. SAN JOAQUIN COUNTY • <br /> MWE3NVIRONMENTAL <br /> HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> JAN 0 M" <br /> e�l one:(209)468-3454 Fax:(209)468-3433 Web:vvww.siaov.ora/ehd UNIT IV <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION <br /> PERMIT'SERVICE&REFUN DABLE 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 /> Assessor's <br /> Well Location 27011 S Austin Road Cross Street Burnham Road City Ripon Zip 95366 Parcel# 181-16-7 <br /> Propert <br /> Owner L pini Farms,Inc. Address 27011 S.Austin Road City Ripon Zip 95366 Phone# <br /> 209-465-8712 <br /> C-57 Contractor Precision Sampling,Inc. Address 2365 Wigwam Drive City Stockton Zip 95205 LIC# 636387 Phone <br /> Consultant/Sub Cntr Herst&Associates,Inc. Address 4630 South Hwy 94-North Outer Road City Saint Charles,MO LIC# Phone 636-939-9111 <br /> GIS Coordinates:X 2148144.43 Y 6366977.10 ,Township 1N Range 7E Section 35 <br /> WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# AMW-30S ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 inch <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Sch 80 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> ❑VAPOR 9 MUD ROTARY DEPTH OF GROUT SEAL 0-94 feet TREMIE TYPE TO BE USED❑AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 5 x 94#Portland Cement&Max 5%Bentonite&100 gal water <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet ❑BOLTED TRAFFIC BOX OR ®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 depared thi application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a b C 'o is La s. <br /> Signed Title/Company Manager-Remedial Services/Herst&Associates,Inc. <br /> Print Name William J.Abern Date January 6,2010 <br /> OF <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ,^ <br /> APPLICATION ACCEPTED BY f b DATE ISSUED j—)7—)f!;0 —AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 41`741 8 \'15 Lk 3 N b SR# =5°'/ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/26/09 WELL PERMIT APP <br />