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San Joaquin County 0 '� <br />Environmental Health Department O SITE <br />600 East Main Street, Stockton, CA 95202-302 Cal�11L_ <br />;�cjy�,1TIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd `'UNIT IV <br />Well Permit Application CA, m/w, -1 0 200 <br />I -IV l <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS 'p�lNT�✓/��'i/ CCnn�� 7�,,� <br />1, p 1 I ��q`}�5i" <br />7A <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described � in compliance with San <br />hHealth <br />CHECK # <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental De akh &t. <br />DATE PERMIT/ SERVICE REQUEST* <br />4010 East Fremont St. Fremont/Oro Stockton 95215 Assessors 143-33029 <br />WELL Location Cross Street City Zip Parcel# <br />PROPERTY <br />272 G 2 <br />Owner Kulwant Sandhu Address 3900 Weston Way City Modesto Zip 95356 Phone# <br />3-27.08 -4W005'374/ <br />C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# 656407 Phone# 925-313-5800 <br />Consultant / Sub Cntr A.G.E. Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# 209-467-1006 <br />COMMENTS: Reference Work Plan dated 12/05/07 & EHD-approval letter dated 01/18/08 <br />GIS Coordinates: X 'y Township Range Section <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />WORK TO BE PERFORMED: <br />vNEW WELL/ BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />)ffSOILBORING# P-17 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: Reference Work Plan, dated 05 December 2007 & EHD-approval letter dated 18 January 2008 <br />SITE MAP IN UNIT IV FILE, ADDRESS: 410o e. ee+ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />7A <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA <br />CHECK # <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br />DATE PERMIT/ SERVICE REQUEST* <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 9S' TREMIE TYPE TO BE USED: ff AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE RPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />272 G 2 <br />WOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br />3-27.08 -4W005'374/ <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH 95' 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NA (if YES, list specifications in comment section) <br />COMMENTS: Reference Work Plan dated 12/05/07 & EHD-approval letter dated 01/18/08 <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 t Title/Company Project Geologist/A.G.E. <br />Print Name Timot y J. Cuellar Date 03-05-08 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 410o e. ee+ <br />WORK PLAN DATED:eCGr .17 �.D0 S <br />`/_�Q <br />O <br />la i L M -n,grn 3 %2 7 '� 8 Are/a/ i �'/S <br />Application Accepted By Y/ G l jr G e lF� r Date Issued <br />Grout Inspection ByVjCja,4, L,W01-f4sr Date #-23 8 Final Inspection ByVIGa'IIYiGi%1� ate 4-21/-0 <br />Destruction Inspection By Date <br />n <br />COMMENTS / CONDITIONS: Adyaji ezew e,,,t add - I ? ZO <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT/ SERVICE REQUEST* <br />INVOICE <br />iso I '.70.aa 383.00 <br />272 G 2 <br />Le/' 2 <br />3-27.08 -4W005'374/ <br />C-57 WC= WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br />EHD 29-02-001 WEB <br />9/11/2007 <br />