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oAco <br /> 'fan Joaquin County <br /> RE <br /> Environmental Health Department QE�--=TE <br /> LO 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN 1 5 2009UNIT IV <br /> ` FORS'` Well Permit Application PP ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 701 East Charter Way Cross Street Stanislaus st City Stockton Zip 95206 Parcel# 147-343-11 <br /> PROPERTY <br /> Owner CHOUHAN,SWARAN Address 1632 PAOLA PL City MANTECA Zip 95337 Phone# (209) 824-7678 <br /> C-57 Contractor Gregg Dr;I l;ng Address <br /> _250 Howe Ave City Ma ;n Zip 94553Lic# 656407 Phone# (925)313-5800 <br /> Consultant/Sub Cnttrrr Advan a Q­Pnyi onmcn -i Address <br /> � 212 Chaor Rr9 City Stockton LIC# FaL2 -- Phone# (20410 <br /> GISCoordinates:X "1? Z -9 <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> 13 NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL �n�_a 0 OVER-BORE. DIAMETER <br /> 0*Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 8.25"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2"_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_SCHD 40 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 8 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 8' TREMIE TYPE TO BE USED: B AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: DYes 0 No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> —TSIpP TT pnrrlanr3 <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 35' bsq 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: Installation of soil va or extraction well Vw-4. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4U 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 Ordinances ule and Regulations) and all applicable California State Laws. <br /> Signed x <br /> Title/Company Project Scientist <br /> Print Name Ai l y rni avi ra <br /> Date 01/15/09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: l <br /> Application Accepted By Date Issued r '. <br /> Area <br /> Grout Inspection By Date1-L3-o � Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK it 5 EC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 353 .;?r 5 19' 29.3`J.3 S R# <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EFM 29-02-001 <br /> 6/22/04 FILE COPY <br />