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San Joaquin County ORIGINAL <br />Environmental Health Department SITE <br />600 East Main Street, Stockton, CA 95202-3029 j�� QEPyrTCATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org h UNIT IV <br />Well Permit Application MAF' 1 Q 2008 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br />OP <br />PE CODES <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. �tp :� iT,4ci le_-ALiompliance with San <br />CHECK # REC'D BY <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental <br />INVOICE <br />4100 East Fremont St. Fremont/Oro Stockton 95215 Assessors 143-33-046 <br />WELL Location Cross Street City Zip Parcel# <br />383.�b <br />PROPERTY <br />3 2? -08 SR# �(� S37¢0 <br />Owner Amrit/Balbir Grewal Address 4100 East Fremont St.City Stockton Zip 95215 Phone# 209-986-0797 <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 />GIS Coordinates: X 'Y Township Range Section <br />WORK TO BE PERFORMED: <br />VIEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />--- <br />VSOIL BORING # P -15A&-- } F- t S B a OVER -BORE. DIAMETER <br />(� <br />0 WELL # 0 PRESSURE GROUT <br />G <br />0 'Other GROUT SPECIFICATIONS <br />COMMENTS: Reference Work Plan, dated 05 December 2007 & EHD-approval letter dated 18 January 2008 <br />4 d <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA _t <br />EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 95 ' TREMIE TYPE TO BE USED: N AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE UPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />WOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <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. 'C <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 Title/Company Project Geologist/A.G.E. <br />Print Name Timoth J. Vuellar Date 03-05-08 <br />DEPARTMENT USE ONLY 1 <br />SITE MAP IN UNIT IV FILE, ADDRESS: q- 10 0 F_Q S+ rf Prn a-iT S+r e -e,"- <br />WORK PLAN DATED: MQ rrl. sf D D $ <br />Application Accepted By ' Date Issued -Q33Area 145-1 _ <br />Grout Inspection By • 2 �� 8 Final Inspection By ` �` a Date y - 7,3-06 <br />Destruction Inspection By A ate y� q� <br />COMMENTS / CONDITIONS: /t� C aB, P-) EA I nd r - Iiic C3 o n .S r + e <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT / SERVICE REQUEST # <br />INVOICE <br />35.0384.00 <br />383.�b <br />ala G2 'el* <br />3 2? -08 SR# �(� S37¢0 <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 />