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fan Joaquin Count <br /> FILE - COPY <br /> j- <br /> Environmental Health Department SITE <br /> } 600 East Main Street, Stockton, CA 95202-3029 !`i FE r•`(r~; _ :111 IT GAT 10N <br /> (2.09)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/r'h -d i&b44IT IV <br /> Well 'Permit Application r. <br /> kl <br /> u iJ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS{Jt<E),ci,11Fy�`rrsll_Y4;i i _ <br /> z <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described wT is3agpltc bri11s<maa `compliance with San <br /> Joaquin County Development Title,Chapter g-1115.3 and the Standards of San Joaquin County Environmental Health <br /> li <br /> Fremont/Oro <br /> WELL Location 4100 East Fremont St. Cross Street City Stockton Zip 95215 Parcel# 143-33-046 <br /> PROPERTY <br /> Owner Amrit/Salbir Grewal Andress 4100 East Fremont St.City Stockton ZiD 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 I 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 f BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> )TSOIL BORING# P-15A&- l F-I tTE 0 OVER-BORE. DIAMETER <br /> 0 WELL 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> T COMMENTS: Reference Work Plan, dated OS December 2007 & EHD-approval letter dated 18 January 2008 <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 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: NA <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 95' 1 TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE WUSH POINT(GP or CPT)GROUTSEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland Type II <br /> 1]OTHER: 0 OTHER APPROX..BORING DEPTH 95' 0 BOLTED TRAFFIC BOX or a 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 03/18/08 <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> I <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed r - 041.r Title/Company Project.Geologist/A.G.E. <br /> Print Name <br /> Timoth J_ Vuellar Date 03-05-08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4- } 0 D Ea S+ rr!!! I)-j S+r e-e+ <br /> WORK PLAN DATED: . Aa rc l ,1, <br /> ' Date Issued -4. Area <br /> Application Accepted By �.- .. <br /> Grout Inspection By •2 -08 Final Inspection By ` r Date <br /> Destruction Inspection By ate q� <br /> COMMENTS I CONDITIONS: V >?e O ,or& &!"F P' l S n-/� �`/S !D o rl.S' +• <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> :3 5-01 �H.D0 383.oa �7� G2 Yl` 3 2.7 SR# Oct 537 ¢0 <br /> C-57— WC -WAIVER, C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9111/2007 <br />