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��U1 San Joaquin County <br /> z/ oy Env.r'bnmental Health Department 916ATION E <br /> ly 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/e IV <br /> Well Permit Application t <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. thk} is "In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Ile ent. <br /> 2057 South E1 Dorado St Delhi Stockton 95204 Assessors 165-153-09 <br /> WELL Location Cross Street City Zip Parcel# <br /> PROPERTY <br /> Owner Charan Dhillon Address 2057 South El Dorado City Stockton ZiP95204 Phone# 321-7607 <br /> Advanced GeoEnvironmental837 Shaw Road Stockton 95215 680227 467-1006 <br /> C-57 Contractor Address City---- ----- Zi Lic# Phone# <br /> Advanced GeoEnvironmental 837 Shaw Road Stockton 680227 467-1006 <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> Xb NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 4SOIL BORING# B-2 and B-3 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: -- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1.2 5°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 TD TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE WUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )4SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Type II portland <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH First GW (30' )0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 ve pr d is application and that the work will be done in accordance with San Joaquin <br /> County Or n les nd egul tions, and all applicable California State Laws. PAYMENT <br /> Signed x Title/Company PM/ADVANCED GEOENVIRONMENTAL, INC. RECEIVED <br /> Print Name ARTHUR DEICKE Date 18 DECEMBER 2006 n1=f 1 p 2006 <br /> DEPARTMENT USE ONLY <br /> SAN JOAQUIN COON <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ENVIRONMENTAL <br /> PAFtTMEP <br /> WORK PLAN DATED: <br /> Application Accepted By an Date Issued D Area < <br /> Grout Inspection By Date t &I I � 0 1_Final Inspection By —Date ' t� v}— <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 PERMIT I SERVICE REQUEST# INVOICE <br /> SR# D. Vz --55 <br /> C-57--I,/ WC -WAIVER' C-57 Letter of Authorization to sign permitAA Encroachment docoill'- <br /> EHD 29-02-001 <br /> 6/22/04 <br />