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raft �f <br />;4".. San Joaquin County <br />.'MA Y 0 4 <br />Environmental Health Department 2004 SITE <br />0 MITIGATION <br />WCA <br />: $ ` 304 East Weber Avenue, 3rd Floor, Stockton, N1�lE(VJ HE <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaquiri�/y �ICES 'h UNIT IV <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 Lammers Road Cross Street 1 lth St. City Tracy Zip Parcel# <br />PROPERTY <br />Owner Ernie Pornbo Address 1755 11 th Street Tracy city Tracy Zip 95376 Phone# 2098354949 <br />C-57 Contractor V&W Drilling Address 1' O. Box 416 City Isleton Zip 95641 Lic# 720904 Phone# 9 167774 100 <br />Consultant / 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 />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER <br />S WELL # Muj-5- t AAA) -j O S 1 v1%j j - 4 r3 O PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />?0 MONITORING }p HOLLOW STEM DIA. OF BOREHOLE 8 7/8 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Varies TREMIE TYPE TO BE USED: jj AUGERS HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat i1ement <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 20 S'50' `BOLTED TRAFFIC BOX or 0 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 Ordin§Ace�„ FjtUles and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Dp-cemb2 <br />Title/Company C OnSUILant: i,4... li'iiAbC i-danz cit, Associates <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued_ <br />Grout Inspection By ✓ '- 1 C - CN --s Date 5- l 40 Final Inspection By <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />Date 4/29/04 <br />/O% Area j,Z/ <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE P EQUEST # <br />INVOICE <br />350( <br />Vq•oo <br />SR#003-4S�J-4- <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 />