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f <br /> I r <br /> San Joaquin County FILE COPY <br /> F � Environmental Health Departmentl�1r���:L, SITE <br /> 600 East MainStreet, Stockton, CA 95202-3029 t�;j ,f1 r MST 1GATIQN <br /> t 09 468-3449 Fax: 209 468-3433 Web: www.s ov.or /ehd `' i=ce t <br /> (? ) ( ) �� � UNIT I V <br /> F-' Well Permit Application 0'w4 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUEby` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe. Trsis'aora,is me in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envifornmental Health Depakt in. <br /> Fremont/Oro Stockton 95215 Assessors 143 33 9 <br /> WELL Location 4010 East Fremont St. Cross Street City Zip Parcel# <br /> -PROPERTY Modesto <br /> Owner Kulwant Sandhu Address 3900 Weston Way City Zip 95356 Phone# <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic#656407 Phone#925-313-5800 <br /> Consultant I Sub Cntr A_G.E. Address 837 Shaw Rd. City Stockton Lic# 680227 Phone# 209-457-1006 <br /> GIS Coordinates:X ,y Township Range Section <br /> WORK TO BE PERFORMED: <br /> VIEW WELL 1 BORING (CPT_GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br />` �[IZOIL BORING# P-17 0 OVER-BORE, DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: Reference Work Plan, —a--b-5 December 2007 & EHD-approval-letter dated 1-8 January 2008 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NA_ <br /> ©EXTRACTION []AIR'HAMMER]DRIVEN CASING THICKNESS. NA TYPE,OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br /> 0 VAPOR 0 MUD ROTARY D6TH OF GROUT SEAL 9.5' TREMIE TYPE TO BE USED: 'nAUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE BUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> VSOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> a 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 /> 4 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 /> 4 County O�fr/dinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed 1,�trTiilelCompany Project Geologist/A.G.E. <br /> Print Name Timothy 7 Cuellar Date 03-05-08 <br /> DEPARTMENT USE ONLY <br /> I SITE MAP IN UNIT IV FILE,ADDRESS: Fr&—m ee.- <br /> WORK PLAN DATED:`, �/ <br /> Application Accepted By t ]r'+1)Ir;'4 L, �1�1 L� r�,�-, _ Date issued 3t. 8 7 '0 Are4-2z1-09 <br /> a/ ` 5• ? a <br /> Grout Inspection By Vi� L,�' ,4&, Date 4-234-0 B Final Inspection Byyj'd7riurnE,� 4 <br /> Date -2 -Q $ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: ktd%lanaf- P 1 r <br /> I <br /> ACCOUNTING ONLY: AID# FAC; <br /> i <br /> PE CODES FEE FIFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3So r 8�•an 3. 0.0 3-27.08 SR# 005374.1 <br /> iso -a9�.oa 38 272 G 2 �2 <br /> C-57_ WC, WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc " <br /> EHD 29-02-001 WEB <br /> 9/1112007 <br />