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o • San Joaquin County • <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Aplication 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 /> Jraquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentQ1 7-090-058,—12,-50 <br /> YELL Location5950 E. Woodbridee cross StreeReartef ick City P Acara o Zip Parcel#AAsssessors <br /> WgB��i�lge Winery by ,,•� �a <br /> (wnerRobert Mondavi AddressPO Box 1260 gtlWo0dbrid9eZiR5258 phone# 209-369-5861 G I."] I " 2 <br /> C-67 Contractor Greg¢ In—Situ Address950 Howe St. Cit�'artinez Zlp94553Ligf656407Phone#925-313-5800 <br /> Consultant/Sub Cntr Kennedy/Jenks Address622 Folsom St. city -F Lic# PhoneA15-243-2150 <br /> WS Coordinates:X-171 "74458 ,Y38" 15802 ,Township 4N Range 7E Section 31, 32 <br /> NORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT)0UbVX5XK HYDROPUNCH,�) D DESTRUCTION (choose type below) <br /> a SOIL BORING# 0 OVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> =Other CPT_ �tn f'PT-9 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING D HOLLOW STEM DIA.OF BOREHOLEZirt&MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL80 ft. TREMIE TYPE TO BE USED: 0 AUGERS D HOSE <br /> DAIR SPARGE/OZONE 7a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )1 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS Neat <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 80 ft. D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 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 Or an es, leyss and <br /> Regulations, and all applicable California State Laws. <br /> Signed z /9/ •//s li"^wyr Title/Company <br /> Print Name � `r�L`1.� L. / rL Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: E�5i�q��—madam-4'QLr�u itir, // / <br /> Application Accepted By gc�"-�`�� Date Issued 3 �J Area �07� <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 /> 1!// as sR# pD <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />