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��Pak"O" <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> k: Well Permit Application <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 701 E. Charter Way Cross Street Stanislaus City Stockton Zip 95206 Parcel# 147-343-11 <br /> PROPERTY <br /> Owner CHOUHAN,SWARAN Address 1632 PAOLA PL City MANTECA Zip95337 Phone# (209)467-0305 <br /> C-57 ContractorAdvanced GeosnvironmentalAddress 837 Shaw Rd City Stockton Zip 95215 Lic#680227 Phone#(209)467-1006 <br /> Consultant/Sub Cntr Same as above Address City Lic# Phone# <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> g NEW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER-) Q DESTRUCTION (choose type below) <br /> E[SOIL BORING#_V1 through V7 <br /> Q WELL# Q OVER-BORE, DIAMETER <br /> Q'Other Q PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: Advancement of soil vapor borings Vl V2 V3 V4 V5 V6 V7 for vapor intrusion investigation. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA. OF BOREHOLE 1.25"0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: na <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS na TYPE OF CASING: Q STEEL Q PVC Q OTHER: na <br /> Q VAPOR -0 MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE gPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes a No (NOTE: MAXIMUM FREE-FA/ / DEPTH IS 30') <br /> d SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS PORTLAND TYPE II <br /> Q <br /> OTHER:_0 OTHER APPROX. BORING DEPTH 5'bsg Q BOLTED TRAFFIC BOX or Q 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 /> 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 Ordi�n{a�nces Ru s and Regulations I and all applicable California State Laws. <br /> Signed x_ (�✓l„ Title/Company Staff Scientist <br /> Print Name Ally Colavita Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued Z g O Area <br /> Grout Inspection By Date 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# 5EC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> 3s63 9Aj.w <br /> 4Z230 Cti74z /�y��& sR# GOS�{97l <br /> C-57 ✓ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 622/04 <br />