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San Joaquin County <br />Envit unmental Health De artp� <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 5_10�L�� <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-j'oa(l�ip,.czt.u�e�#j7 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DNTX,I$ LEQ1„IEAI HF:A1 f ! <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work desol-ibed. This Epp i atlion 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# z2i—P&O -I'S <br />PROPERTY <br />Owner Manteca Schools Address P.O. Box 32 City Manteca zip 95336 Phone#LLf'0 ga.f 3Zvv <br />C-57 Contractor V&W Drilling <br />Address P.O. Box 970 City Lodi Zip 95241 Lic# 720904 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 />0 NEW WELL / BORING (CPT, EOPROB HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />,E SOIL BORING # Three <br />0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-' 30.x— TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE >a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nl✓i 1 CEMP_A)= <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 30' 0 BOLTED TRAFFIC BOX or 0 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 ha I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordina 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: <br />WORK PLAN DATED: SI O I 9I DI <br />Application Accepted By ( �yf ` Date Issued O Area bZ11 <br />Grout Inspection By Date 6 24 o Final Inspection By Date <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE EST # <br />INVOICE <br />3 solsn <br />3 So i <br />0 a.gs`"o0 <br />6 z6 3 <br />5_ f41o} SR#0D5 o62.3 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ -1 nc <br />EHD 29-02-001 <br />9/30/2002 <br />