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San Joaquin County <br />Environmental Health Department R SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd vA ZANIT IV <br />� 696 34, Well Permit Application � raa�C tC <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 In compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental I (e,W[SeVaft'ment. <br />{t <br />WELL Location 2057 South E1 Dorado St Cross Street Delhi City Stockton Zip 95204 parcel# Assessors 165 -153 -OS <br />PROPERTY <br />Owner Charan Dhillon Address 2057 South El Dorado City Stockton Zip95204 Phone# 321-7607 <br />C-57 Contractor <br />Advanced GeoEnvironmen Address 837 Shaw Road City Stockton Zip 95215 Lic# 680227Phone# 467-1006 <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*) <br />)USOIL BORING # B-2 and B-3 <br />0 WELL # <br />0 *Other <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.25"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 />Xff SOIL 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 have pr d t is application and that the work will be done in accordance with San Joaquin <br />County Or h$ s les nd egul tions, and all applicable California State Laws. DAYNAE IN f <br />Signed ` Title/Company PM/ADVANCED GEOENVIRONMENTAL, INC. DECEIVED <br />Print Name ARTHUR DEICKE Date 18 DECEMBER 2006 �lCr p �oOC <br />DEPARTMENT USE ONLY U <br />SAN JOAQUIN COUNTY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ENVIRONMENTAL <br />PARTMENT <br />WORK PLAN DATED: <br />53 <br />C� <br />All <br />Application Accepted By V- Date Issued G Area < <br />Grout Inspection By Date t j -5l L P-1— Final Inspection By Date .q LT < (d -+- <br />Destruction Inspection By Date <br />COMMENTS/CON <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />371(. vqa <br />S' <br />Q(tflC,L_ <br />SR# <br />C -57--I,/ WC_,/WAIVERC-57 Letter of Authorization to sign permit Encroachment docpl <br />EHD 29-02-001 <br />6/22/04 <br />