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San Joaquin County <br /> Environmental Health Department ,:, ��� SITE <br /> 2!iU <br /> 600 East Main Street, Stockton, CA 95202-3029VIITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sjgov.or-/ehd ( ;-'D�,-'� <br /> U <br /> _ _ . NIT IV <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 /> Assessors <br /> WELL Location 1444 South Lincoln Street Cross Street W. Charter WaVty Stockton Zip 95206 Parcef# 16503005 <br /> PROPERTY <br /> Owner Mr. Edward Overton Address P.O. Box 417 City French CampZip 95230 Phone# 630-598-8117 <br /> C57485165 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Zip 94553 Lic# Phone# 975-313-5800 <br /> Consultant/Sub Cntr PSC Address 210 W. Sand Bank Rd.City Columbia 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 /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 1 SOIL BORING# CPT-M4 th,rou'gn'CPT-M12 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> *Other___ _ GROUT SPECIFICATIONS <br /> COMMENTS: Nine CPT borings and up to " adjacent hydropunch borings. <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: <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: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 125 ft. bgs. 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 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 /> County Ordinances, R es a d^Regulations, and all applicable California State Laws. <br /> Signed x 7 �'�JG1/� Title/Company Project Manager <br /> Date O 4ef3 <br /> Print Name Paul Anderson <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: `t`7 n "\— <br /> WORK PLAN DATED: <br /> Application Accepted By_ � ' Date Issued /3 G 7 Area <br /> Grout Inspection By Date Final Inspection By ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 36y SR# .5351 3 <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 />