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oa Wan Joaquin County <br /> c Environmental Health Department ) J (C JE� TE <br /> a 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 ATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd ,JAN 15 2009UNIT IV <br /> FoRN`P Well Permit Application 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 stanielaus at City Stockton Zip 95206 Parcel# 147-343-11 <br /> PROPERTY <br /> Owner CHOUHAN,SWARAN Address 1632 PAOLA PL CityU6NL A Zip95337 Phone# 1209) 824-7678 <br /> C-57 Contractornre,gg prillina Address 950 Howe Ave. City _Zip 94553 LIC# 656907 Phone# (925)313-5800 <br /> Consultant/Sub Cntr aavan a -P uyironmental Address A17 Ahaij PA CityStockton Llc# 680227 Phone# !2091467-1006 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> B NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 5 WELL# VW-4 0 PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING a 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 /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 8' TREMIE TYPE TO BE USED: flAUGERS 0 HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: CtYes p No (NOTE: MAXIMUM FREE-FA// DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Myqpp TT Pnrti gnd <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 35' bsq 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (N YES,list specifications in comment section) <br /> COMMENTS: Installation of soil vapor 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 an Regulations) and all applicable California State Laws. <br /> Signed Title/Company Proi ect Scientist <br /> Print Name Ally r i avit _ Date 01/15/09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /,� <br /> Application Accepted By j/1e� T��+°��J�'1 Date Issued //Z Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# *FAC#PE CODES FEEINFO AMOUNT REMITTED CHECK# DATE PERMIT/SERVICE REQUEST# INVOICESyG4/ 293' sR#BOSG3 9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />