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. '� San Joaquin County <br /> Environmental Health Departmental` SITE <br /> h 4 600 E. Main Street Stockton CA 95202-3029 -- r %f ri P <br /> ' `,P, v4 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.Sjgov.org/ehd <br /> \ UNIT IV <br /> Well <br /> 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 /> WELL Location 3230 North West Lane Alpine/West LN. Assessors �S <br /> Cross Street City Stockton Zip 95204 Parcel# 117-08017 2.0 <br /> PROPERTY <br /> Owner Johal Dalbir Address 3230 N. West Lane Stockton <br /> City Zip 95204 Phone# 209-992-7634 <br /> C-57 Contractor A.G.E. Address 837 Shaw Rd. Stockton 680227 <br /> City Zip 95215Lic# Phone# 209-467-1006 <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic# 680227 phone# 209-467-1006 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> xj3NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> 9GOIL BORING#P-13, P-14, P-15 <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> Q <br /> Q PRESSURE GROUT*Other GROUT SPECIFICATIONS <br /> COMMENTS: See EHD-Approved Work Plan, dated 20 September 2007 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE 2" Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: <br /> Q AIR SPARGE/OZONE TPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q AUGERS Q HOSE <br /> �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> X12)SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br /> Q OTHER:_G OTHER APPROX.BORING DEPTH 5' <br /> Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x it Title/Company ADVANCED GEOENVIRONMENTAL, INC <br /> Print Name TIMOT J. CUELLAR Date 25 FEBRUARY 2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT!V FILE,ADDRESS: 4236 o i^ {-�, �/�f LAS Lane. <br /> WORKPLAN DATED:r' F'ebr . aYy 2U6g (Ina( IS 2nQ 7 a4dj�tp, ke,-,2 0200'7° <br /> Application Accepted By 1( t d'+b Y Date Issued 2 2 — Area <br /> Grout Ins ection B / <br /> P Y�L t CL*-) C(��itgl Date „2-2 q -0 Final Inspection By i!Y Yj <br /> Destruction Inspection By �_ Date <br /> COMMENTS/CONDITIONS: f —(3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35°03 .214.00' #383. ov 2687'3 z1a//o8 SR* 0453 <br /> C-57_ WC`WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 web <br /> 6/22/04 <br />