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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web: www.sigov.org/ehd UNIT I`✓ <br /> 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 /> Assessor's <br /> Well Location 1444 S. Li ncol n St. Cross Street W. Charter Way City Stockton Zip 95206 Parcel# 16503005 <br /> Property <br /> Owner Mr. Edward Overton Address P.O. Box 417 City French Camp Zip 95230 Phone# 630-598-8117 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road 057485165 <br /> City Martinez Lic# Phone 925-313-5800 <br /> Consultant/Sub Cntr PSC Address210 W. Sand Bank Rd. City Col umbi a Lic# Phone 618-281-1543 <br /> GIS Coordinates:X 121.293579 Y 37.936946 Township 1 North Range 6 East Section 15 <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') E]DESTRUCTION(CHOOSE TYPE BELOW) <br /> [I SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# CT-MW-8-80, CT-MW-8-120, CT-MW-9-120 ❑PRESSURE GROUT <br /> FJ-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: 3 groundwater monitoring wells to be installed, one to approx. 80' bgs and two to approx. 120 bgs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NVA <br /> ®MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 211 ^ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS Sch. 40 TYPE OF CASING:❑STEEL ®PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 661, 106' TREMIE TYPE TO BE USED❑AUGERS iBl HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 ft. bas* II BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 /> Regulations,a d)all appliiccSble�Californiia Lows. <br /> Signed CJ-�5 Title/Company Project Manager/PSC <br /> Print Name Paul Anderson Date <br /> X / �`- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `ti L-Aly <br /> WORK PLAN DATED: �-t r7 W lVt/ S,tiG Z 7 <br /> APPLICATION ACCEPTED BY I �' DATE I ED 41,14 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 /> o <br /> 11l.,v1"> 1Df_ Z� S' z`tL SR# "kA2-1' <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ' ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) FILE <br /> COPY ERMIT APP <br />