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y" x San Joaquin County <br /> Environmental Health De artment MAY 0 4 2004 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA khMQNMENT MITIGATION <br /> Ili HEALTH UNIT IV <br /> c (209)468-3449 Fax: (209)468-3433 Web: www. o.san joaq VICES <br /> R�lP0 �� <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 <br /> WELL Location 24100 S La niers Road Cross Street 11th St. City Trac Zip Parcel# <br /> PROPERTY <br /> Owner Ernie Pombo Address 1755 11th Street Tracy city—'Fracy city-'racyZip 95376 Phone# 2098354949 <br /> C-57 Contractor V&W Drilling Address P.O.Box 416 ity Isleton Zip 95641 Lic#72090 "Phone# 216zu4100 <br /> Consultant I Sub Cntr M.J.Kloberdanz&Associates Address P.O.Box 576981 City Modesto Lic# Phone# 2095778186 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#I Ift 10V FIAW t A&kH 0'9 4- M W q--y3 0 PRESSURE GROUT <br /> p"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> c <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )a MONITORING HOLLOW STEM DIA.OF BOREHOLE 8 7/8 ©MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2"_ <br /> 0 EXTRACTION ©AIR HAMMERIDRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUGERS J]HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Y 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 20 50' VOOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED nn (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUI ED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that theA ork will be done in accordance with San Joaquin <br /> County Ordin ce les and Regulations, and all applicable Cal fornia State Laws. <br /> Signed x TtlelCom any Consultant: M.r. Kloberdanz&Associates <br /> Print Name Mich J. Kloberdanz Date 4/29/04 <br /> DEPARTMENT US H ONLY VILL <br /> jiuri <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 24100 S Lammers Road, Trac <br /> WORK PLAN DATED: <br /> Application Accepted By ate Issued Area Z-1 <br /> Grout Inspection By Date 0 _Final nspection By 05 Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Say SR# - - <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit,Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/30/2002 <br />