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4. <br /> San Joaquin County <br /> Envillonmental Health Depart `� �'�/1i �" SITE <br /> 304 East Weber Avenue 3rd Floor Stockton CA �i� MITIGATION <br /> cT.... P (209)468-3449 Fax: (209)468-3433 Web: www.co.sanjoa4p.jwcq.uge�l17 UNIT IV <br /> 9 l 0 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D!ENMggj1—N1 11E_r1Li _ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dLNi: e'd:!9.41'pjjliQon 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 660 Mikesell Avenue Cross Street Garfield City Manteca Zip 95336 Parcel# zZl-my-{3 <br /> PROPERTY <br /> Owner Manteca Schools Address P.O. Box 32 city Manteca Zip 95336 Phone#(L--0 TZf 3zv0 <br /> C-57 Contractor V&W Drilline Address P.O.Box 970 City Lodi Zip 95241 Lic#72090a Phone#_209-369-9600 <br /> Consultant/Sub Cntr M.J. Kloberdanz&Assoc.Address P.O. Box 576981 City Modesto Lic# Phone# 209-577-8186 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT, EOPROB HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> x0 SOIL BORING# Three 0 OVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL %J 30_-� TREMIE TYPE TO BE USED: []AUGERS D HOSE <br /> 0 AIR SPARGE/OZONE >[k PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> x®SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NEAT C_e—MEAJT' <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH 30' 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: See Work Plan dated 7/26/01 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify tha <br /> I have prepared this application and that the work will be done in accordance with San Joa in <br /> County cel <br /> c s le nd Regulations, and all applicable California State Laws. <br /> Signed x Title/Company M.J. Kloberdanz &Associates <br /> Print Name Michael J. Kloberdanz Date May 14,2007 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 610 0 I(W uexA� <br /> WORK PLAN DATED: _ O( <br /> Application Accepted By-__Wnn yf` Date Issued D Area b7_11 <br /> Grout Inspection By Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35'dl 8`Ot-pO 6z63 SR# <br /> Li To 5O�i27j <br /> *S oa"gSa00 <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 />