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San Joaquin County <br />Envii nmental Health Department SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: vvww.co.san-joaquin.ca.us/ehd 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 223 W. Washington St./514 Key Ave. Cross Street Key Avenue City Ripon Zip 95366 Parcel# 261-060-13 <br />PROPERTY <br />Owner RP: Nagab Elsumri Address 223 W. Washington St. City Ripon Zip 95366 Phone# 209-599-5403 <br /> <br />C-57 Contractor V&W Drilling Address P.O. Box 416 <br /> <br />City Isleton Zip 95641 Lic# 720904 Phone# 916-777-4100 <br /> <br />Consultant / Sub Cntr M.J. Kloberdanz & Assoc. Address City Lic# Phone# <br />GIS Coordinates: X Township <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") <br />SOIL BORING # <br />)111}.WE LL # I well 40 to 50' deep <br />fl *Other <br />TYPE OF WELL INSTALLATION TYPE <br />liMONITORING *HOLLOW STEM <br />El EXTRACTION a AIR HAMMER/DRIVEN <br />a VAPOR UMUDROTARY <br />Range Section <br />0 DESTRUCTION (choose type below) <br />1:1 OVER-BORE. DIAMETER <br />c— <br />C- 6 <br />_ <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: Well will be located at 514 Key Avenue near the former UST excavation. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 8 7/8 a MULTIPLE CASINGS 1:1 MULTI-LEVEL WELL CASING DIA: 2 in. <br />CASING THICKNESS sched, 40 TYPE OF CASING: U STEEL *..PVC a OTHER: <br />DEPTH OF GROUT SEAL 35 to 45 TREMIE TYPE TO BE USED: ['AUGERS &HOSE <br />AIR SPARGE/ OZONE [I PUSH POINT (GP or CPT)GROUT SEAL PUMPED: SYes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING U HAND AUGER GROUT SPECIFICATIONS cement <br />OTHER: 13 OTHER APPROX. BORING DEPTH 40 to 50' <br />CONDUCTOR CASING PROPOSED no <br />COMMENTS: see Work Plan 5/31/05 <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 Ordi s, ules and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />Title/company Consultant: M.J. Kloberdanz & Associates <br /> <br />Print Name Michael J. Kloberdanz Date 08/02/05 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (,)a. <br />WORK PLAN DATED: SI 31 ) <br /> <br />&BOLTED TRAFFIC BOX or a STOVE PIPE <br />(if YES, list specifications in comment section) <br />Application Accepted By NKLAA.,\.rel (— <br /> Date Issued <br /> o <br />Area A 2_12 <br />Grout Inspection By <br /> <br />Date <br /> <br />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 ST # INVOICE <br />3o3 -10, 3'1 ,(2'-' 5" S" 2- 3-- (L--( 8- g - SRitti 3Li 23 <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit <br /> <br />El ID 29-02-001 <br />9/30/2002