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,pan Joaquin County J <br /> Environmental Health Department _SITE <br /> i¢ {j 600 East Main Street, Stockton, CA 95202-3029 j MITIGATION <br /> r�M <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd F` UNIT IV <br /> \,FORS Well Permit Application <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 /> Assessors <br /> WELLLocation 3230 North West Lane Cross Street Alpine Ave. City Stockton Zip 95204 Parcel# 117-080-17 <br /> PROPERTY <br /> Owner Dalbir Johal Address 5955 Mustang Place City Stockton .Zip 95210 phone# (209)992-7634 <br /> Gregg Drilling & <br /> C-57Contractor Testing, Inc. Address 950 Howe Road City Martinez Zip 94553 Lic#485165 Phone# (92S)313-S800 <br /> Advanced <br /> Consultant/Sub CntrGeoEnvironmental, Inc. Address 837 Shaw Avenue City Stockton Lic# 680227 Phone# (209)467-1006 <br /> _GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ROVER-BORE. DIAMETER 20" (3' bsq only) <br /> 0 WELL# g PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS Type I/II Portland <br /> COMMENTS:Well casings will be pressure grouted. Well to be destroyed: MW-1, MW-2, MW-3, MW-4 and MW-5R, 'fills <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 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 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 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-WOR-KING-HOURS-NO-T-ICE-REQ JIR.ED-FOR INSP�C-T-IONS.- ---- <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 Vice President /. Advanced GecEnvironmental, Inc. <br /> Print Name Roberty E. . arty Date 27 October 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: VV,-_vs+ Lane, <br /> WORK PLAN DATED:/ N A <br /> Application Accepted By V i r-+o r; et, /YI /91,+12 Date Issued ' 2 -0q �J� <br /> Area 14.53 <br /> / <br /> Grout Inspection By Date Final Inspection By 11;e_+o� ��^¢AJte 11-LO • 02 <br /> Destruction Inspection By Y't+a r'&M Y Date j 1-,20 -0 <br /> COMMENTS/CONDITIONS: f yn 0 -3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3503 405.00 $US, 00 - 30307 <e� 11-2- 09 SR# UOS 9 <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 />