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Qeq"! o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> Effl-QP <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> hone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> r <br /> JAN 2 1 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT tHEAETH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplicatiDn WT,lnaagUlMoaquin 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. Lincoln StreelCross Street W. Charter Way City Stockton Zip 95206 Parcel# 16503005 <br /> Property <br /> Owner. Edward Overton Address P.O. Box 417 City French Camp Zip 95230 Phone# (630) 598-81.17 <br /> C-57Contractor TEG Northern CA, IncAddress 11350 Morier Park Place City Rancho CordovaLlc# 706568 Phone (916) 853-8010 <br /> Consultant/SubCntr PSC Address 210 W. Sand Bank Road City Columbia, IL 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 WEWBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# > ❑PRESSURE GROUT <br /> *OTHER SG-1 through SG-7 t Sts A�jF'v""k �' SG-4 / GROUT SPECIFICATIONS <br /> COMMENTS: Seven soil-vapor borings. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE <br /> �_ ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> I]VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> I]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 Abanddnnbbreho+6s Vii th neat cement to surface <br /> ■OTHER: 1" borehole ❑OTHER: APPROX.BORING DEPTH 6 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> for vapor 5 amp rl no. 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 /> Regulations,and all ap icable California Laws. <br /> Signed 2 ew"4rl ri Title/Company PSC / Project Manager <br /> Print Name Paul Anderson Date 1 Zd 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �E ��lwloLk 5 <br /> WORK PLAN DATED: �- O o <br /> APPLICATION ACCEPTED BY DAT ISSUED 1 I Z740 AREA 349 L <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE t <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMIT/SERVICE# INVOICE <br /> tot o I. 801.0,> ii -o J W%IL ot 1'�104- LZ ra 1 SR#5 (o <br /> C-57x WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EMD 29-01 11/5107(UVEB) WELL PERMIT APP <br />