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• PAY ���, <br /> �E�E.IVEG <br /> 1, �� " SAN JOAQUIN COUNTY <br /> ; ENVIRONMENTAL HEALTH DEPARTMENT ����� � <br /> h , N SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 N <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sf ov.oMO <br /> WELL PERMIT APPLICATION SEP 0 3 2008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEbxim/11 "Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl '1Aith San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dep <br /> 3940 N TRACY BLVD LARCH RD TRACY 95304 Assessor'S212-200-04 <br /> Well Location Cross Street City Zip Parcel# <br /> PropertyCHARANJIT & DAVINDER JUTLA 3940 N TRACY BLVp TRACY 95304 832-5006 <br /> Owner Address City Zip Phone# <br /> C-57 Contractor ADVANCED GEOENVIROUNFrNL L 837 SHAW ROAD City STOCKTON Lic# 680227Phone 467-1006 <br /> ADVANCED GEOENVIRONMENTAL 837 SHAW ROAD STOCKTON 467-1006 <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEWWSOLL ORING( ET,IGEOfRgBEWY? Cffy4CHBHP�NDtlGe,o_ 1E1 -8 DESTRUCTION <br /> ESTREl CTIONORE (CHOOSE TYPE BELOW) <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.25 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5 FT TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE )Q PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS TYPE I I PORTLAND <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 FEET ❑BOLTED TRAFFIC BOX OR ❑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 prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio=d11ticifornia Laws. <br /> Signed Title/Company VICE PRESIDENT/ADVANCED GEOENVIRONMENTAL INC <br /> Print Name ROBERT E. MARTY Date 09-03-2008 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: J <br /> APPLICATION ACCEPTED BYDATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> .Z.3 e53:�5 C SR <br /> C 57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E ROAC MENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />