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EVEVYSan Joaquin County <br />Environmental Health Department <br />600 E. Main Street, Stockton, CA 95202-3029 FEB 2 5 2.008 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />-NVEONMENT HEALTH UNIT IV <br />PERMIT/SERVICES Well Permit Application <br />AL <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 />Alpine/West LN. Assessors 2...- WELL Location 3230 North West Lane Cross Street City Stockton Zip 95204 Parcel* 117-08017 <br />PROPERTY <br />Owner Johal Dalbir 3230 N. West Lane City Stockton zip 95204 Phone* 209-992-7634 Address <br />C-57 Contractor A.G.E. Address 837 Shaw Rd. City Stockton zip 95215Lio#680227phone# 209-467-1006 <br /> <br />Consultant / Sub Cntr A. G . E . Address 837 Shaw Rd. City Stockton Lin* 680227 Phone* 209-467-1006 <br /> <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />Xig NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />!MOIL BORING # P -13, P -14, P -15 <br />a VVELL # <br />a *Other <br />COMMENTS: See EHD-Approved Work Plan, dated 20 September 2007 <br />a DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />C-3 <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS :13 <br />a MONITORING a HOLLOW STEM DIA. OF BOREHOLE 2 " a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: () <br />O EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />O VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5 ' TREMIE TYPE TO BE USED: g AUGERS a HOSE <br />fl AIR SPARGE/ OZONE 4:t(PUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes 4:1 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />XIMOIL BORING a HAND AUGER GROUT SPECIFICATIONS TYPE II NEAT CEMENT (PORTLAND) <br />OTHER: U OTHER APPROX. BORING DEPTH 5 ' a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE 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. 9. till., Signed x Title/Company ADVANCED GEOENVIRONMENTAL, INC <br />Print Name TIMOT J. CUELLAR Date 25 FEBRUARY 2008 <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 230 Nor+h Wcsi- Lane. <br />WORK PLAN DATED: February .2.5- 1 2,068 a ri 0( OcAblle 152,90'7 a461 <br />Application Accepted By V i t!.-+-b r ; Gli., L. M C. e.4 r +71.e. y Date Issued a -.21- 0 8 <br />Grout Inspection By V te2ITY ir 4 )1l e".44- Date a-2./ .c. 8 Final Inspection By / <br />1.x.±__ j4_ktr4Ldwv <br />Destruction Inspection By Date <br />2007 <br />Area <br />ate 2-.-2.1 -0 <br /> <br />COMMENTS! CONDITIONS A4( va eruf of i° —13 P-14 Gino( P-iY" barin s 0)7S <br />ACCOUNTING ONLY: AID* FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE P INVOICE <br />4---- — <br />3501 <br />350 3 '‘'.294. <br />009.00 <br />00 <br /># <br />383.00 2 G 8 7 .3 `1171 2/2 7/0_ SR# 0 0 5,3 +t, # <br />C-57 WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit <br />EHD 29-02-001web <br />6/22/04