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98/03/2005 14:52 209-577-8258 MJ KLABERDANZ PAGE 02 <br /> San-Joaquin County 114ed <br /> Environmental Health Department SITE <br /> 304 East.Weber-Avenue,3rd Floor,Stockton, CA 95202 MITIGATION <br /> (249)468-3449 Fax: (209),468-3433 Web:www.co.saa-joaquin.ca.us/ehd UNIT Ill <br /> 6 <br /> NON-REFUNDABLE'PLEP AIT EXPIRES t YEAR FROM DATE ISSUED <br /> APplkation is hereby made to Son Joaquin County for,a perrnit-to constrict and/or install the work described. This applLcation is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Japquin County Irnvironmamal H*04h Oapartment. <br /> WELL Locationas <br /> 223 W.Whint 0_StJ514 Key Ave.Crass Street Assessors <br /> ve ue City Ripon Zip 566 Paroegl 261-066-13 <br /> PROPERTY <br /> Owner RP:N Elsunxci Address 223 W. WNhinaton St.CRY ft2n ,_ZIP 9Ub1_Phone#.209-S44-; 403 <br /> C-57 ContraGar Yew LhjUjRg, ._ Addreas E.Q.Sox416 City AkVAn_Zip.9-smi Lie#72o9b4 Phone# <br /> ConeuUM/Sub Cntr. MJ.YJ2b +dant$o,ASsLo,Address Gity Liril Phonal <br /> GIS C.00nilnetes:x ,.YTownship.`.- .,Range Saclion <br /> VIM TO W PEREQMEQ., <br /> A Nee WELL f BORING (CPT,GEOPROBE,HYDROPUNC}f,HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> 1]SOIL BORING# n OVER-BORE. DIAMETEFZ__-. <br /> j@114ELLds 11 PRESSURE GROUT <br /> a AM GROUT SPECIFICATIONS <br /> COMMENTS: Well will be IOCNE#ed at t1j5g Avenge near the former UST excavation. <br /> TYPE IE I MLL INSTALLATIM TYPE 00WRIUMON Sef&IFICATIONS <br /> AgMONITORING j4HOLLOW STEN! DIA.OF BOREHOLE 9 718 d MULTIPLE CASINGS it MULTI-LEVEL WELL CASING DIA: 2 in. <br /> p EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS shed,40 TYPE OF CASING: 0 STEEL *.PVC 0 OTHER:- <br /> 0 VAPOR 0 MUD ROTARY. DEPTH OF GROUT SEAL 35 go TREMIE TYPE TO BE USED: 0 AUGERS MDSE <br /> 0AIR.SPARGFI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED; OYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> .0 SOIL.BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ©OTHER n OTHER APPROX.BORING DEPTH 44 to 50, &BOLTED TRAFFIC SOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ^,.(i( YES,fist specifications in comment section) <br /> crol+ ENT$: see Work Plan 5/3-1/05 <br /> NOTE: OFFSITE BORINGS REQU#RE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereW cer ft that I have PiroMed this KPPIICatlon and that the work will be done in accordance witty San Joaquin <br /> Courter ul card Regulations,and all applicable CalllbMla State Laws. <br /> So*x . Titie/Company Consultant: M1 Kloberdanz&Associates <br /> :Past Name_MigbM)J.Kiobei+denz _-- ___-- _ -__--_ -- __ _ _ Date 48/02/05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS:.. _ 3 l.J OL-2_ <br /> WORK PLAN DATED:T�o�� <br /> Application Accepted By Date Issued $ �O 5/ Area <br /> Grout Ins}arm lir Date x 1- o Final Ingmction By ,i Date <br /> Des6uotim'i Inspection By • Date <br /> CO MMEN75 I cutlrllxtToNs. <br /> ACCOUNTING ONLY, AID# FAC# <br /> PE COM FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST* INVOIGC <br /> 3 S Q 5'gz6 ® SR# <br /> o � .vcJ. <br /> C-57 Wi-WArVER____ C-57 Letter of Authorization to sign Permit Encroachment clot <br /> EHD 29-02.001 <br /> 9/34!2002 <br />