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AdP4U•IN., t, <br />• '.QG <br />A <br />_...,::1•%i"ij 4th , <br />*San Joaquin County <br />C ' <br />Environmental Health Department Nu ✓ SITE <br />600 East Main Street, Stockton, CA 95202-3OZ9 1 2iJ07 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.t�ZR&Nh4ENT HRMIr��ELry UNIT IV <br />� A <br />Well Permit Application VICE <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby ade to San J uin C&unt r p+ndards <br />construct and/or install the work described. This application is made in compliance with San <br />Joaquin County D:ntatle, 11 5 of San Joaquin County Environmental Health DepartmentAssessors <br />WELL Location Cross Street City Manteca Zip 95336 Parcel# <br />PROPERTY <br />Owner Costco Wholesale Address 999 Lake Drive CityIssaquah,WA Zip58027 Phone# (425) 313-8100 <br />C-57 Contractor Not Required Address City Zip Lic# Phone# <br />BarVhausen Consulting <br />Consultant/ Sub Cntr Enqineers, Inc. Address 18215 -72nd Ave. S. City Kent, WALic# Phone#(425) 251-6222 <br />Lattitude Longitude <br />GIS Coordinates: X 3704714.7111 N , Y 121 ° 15' 4 4.05" W, Township Range Section <br />WORK TO BE PERFORMED: <br />8 NEW WELL 1 BORING <br />II SOIL BORING # <br />0 WELL # <br />0 'Other <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) DESTRUCTION (choose type below) <br />a OVER -BORE. DIAMETER <br />a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />9 MONITORING m HOLLOW STEM DIA. OF BOREHOLE N/A a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 6 in . <br />EXTRACTION © AIR HAMMER/DRIVEN CASING THICKNESS --1/8 in. TYRE OF CASING 11 STEEL flPVC 0 OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br />�] AIR SPARGE! OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes H No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS N/A <br />Perforated <br />0 OTHER: BOTHER Pim 19 ft APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or O STOVE PIPE <br />in rFill CONDUCTOR CASING PROPOSED NO (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 />Director of Real Estate Development/ <br />Si nod x t Title/Company Costco Wholesale Corporation <br />9 <br />Print Name Kim Sanford Date %% I- 4d l <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted <br />DEPARTMENT USE ONLY <br />Issued <br />Grout Inspection By Date Final Inspection By ware <br />Destruction Inspection By Date <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # <br />.?3 F5 1 S1 <br />FAC# <br />REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />S R# <br />C-57— WC -WAIVER! C-57 Letter of Authorization to sign permit_ Encroachment doc, <br />12414,004.pdf <br />EHD 29-02-001 WEB <br />9111/2007 <br />