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06/01/2009 08:50 2094683433 EHD PAGE 02 <br /> �C vtu <br /> SAN JOAQUIN COUNTY AY 'L g 2D09 <br /> ` ENVIRONMENTAL HEALTH DEPARTMENNI SITE <br /> 600 East Main Street,Stockton,CA 95202-3 �il�o�MENT�ICE3 t�NIT IV N <br /> ' Telephone:(209)468-3449 Fax:(209)468.3433 Web: <br /> WELL. PERMIT APPLICATION <br /> NON-REFUN ABLE P R IREB YEA FROM DA E ISSUED <br /> s appliostion is <br /> Joaaquuiin4County Devemade to San opmentTitle,Joaquin <br /> 9-1115,3 and for a Ne Standarmit to ds of Sonlor Joaquin11County Environmental iealth Department, A iesmirsienee wqb San <br /> Asses�ys <br /> ' Wall Location 1444 S. Lino v Cross Street' Charter Way M Stockton 7JP 95206 Parcel#I03005 <br /> Property French Camp ZIP 95230 Phone# 630-598-8117 <br /> Owner Mr. Edward Overton Address P•0. Box 417 Cin C57485165 <br /> C-57 Contractor Crepe Dr111ing Address 950 Howe Road City Ftartinez Lic# �PhDne 925-313-5800 <br /> Consulto AcbbCnk PSC Address 210 W. Sand Bank Rd. C{ty Columbia Ran <br /> Phone 618-281-1543 <br /> Range 6 East Section 15 <br /> GIS Coordinates:X ^3t 39x579_ _,Y_,}j, 6 1 -• <br /> Township 1 NOft� <br /> ' WORK TO RE PERFORMED: O DESTRUCTION(CHOOSETYPE BEtDW) <br /> ❑NEW WELUBORING(CFT,GEOPROBE,HYOROPUNCH.HAND AUGER,OTHERT ❑OVER-BORE DIAMETER, <br /> ❑SOIL BORING# ❑PRESSURE GROUT <br /> K3 WELL# CT-NW^ - 0 CT-MW-B^120 CT-MW-9-120 GROUT SPECIFICATIONS���� <br /> ❑-OTHER , rox. 120 bgs <br /> ' 3 groundwater monitoring wells <br /> to be installed one to approx. 80 b9s and two to a p <br /> COMMENTS: 9 <br /> I STALLAT ON TYPE CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL �.-1---�— <br /> (�MONITORING 13 HOLLOW STEM DIA OF BOREHOLE 81 0 MULTIPLE CASINGS E3 MULTILEVEL WELLCASINGOIA: 2�� <br /> TYPE OF CASING![3 STEEL KIPVC ❑ OTHER <br /> ❑EXTRACTION ❑AIR HAMMEAIORNEN DEPTH OF GROUT SEAL66 TREMIE TYPE TO BE USED❑AUGERS W HOSE I <br /> ❑VAPOR El MUD ROTARY <br /> ' O AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT),_GROUT SEAL PUMPED:M Yes P Ni) (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING E3HAND <br /> AUGER GROUT SPECIFICATIONS Neat Dement <br /> APPRO7C BORING DEPTH, .S�bA+.. BOLTED TRAFFIC o .pnBOX OR O STOVE PIPE <br /> (]OTHER: ❑DntER: CONDUCTORCAMNG PROPOSED IITTES,IktepCncYCn �n,PCalmdbA) <br /> ' COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> t1 hereby cerBTy that I have prepared this application and that the work will be done 1 aceordanoe with San Joaquin County Ordinances,Rules and <br /> Projec <br /> Sigulaibns, Il appy Ie CaY mi <br /> oaL ws. <br /> Signed t Nana er/PSC <br /> TitielComPeM' _ <br /> ' —J--�T� <br /> -ate - <br /> PrinlNemR flaul And rsa <br /> DEpAARRT{MENTI USE ON Y <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: �•' - <br /> WORK PLAN DATED: Lt) <br /> DATE ISSUED -vot ARS` <br /> APPLICATION ACCEPTED BY DATE <br /> FINAL INSPECTION BY <br /> GROUT INSPEOTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> ' COMMENTSIOONDIITONS: <br /> ACCOUNT GONLY-. AID# FAC# <br /> ' RECY'D BY DATE PERMITISERVICE# INVOICE <br /> CHECK# <br /> PE CODES FEE INFO AMT REMITTED <br /> cL„co Alf vo SL s' 2'1 $R#'"�V'1' <br /> -WAIVER 057 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT OC <br /> — <br /> C-57 WC wEU PERMtrAPP <br /> larosso+ +trs+or Mlm) <br />