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�o Ufa �a n Joaquin County <br /> ZA Environitiental Health Departmeiff�1,�.F 1--��/ SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 .LL' <br /> ITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orj/ehd' 5 2007 UNIT IV <br /> cgL; oR�`P Well Permit Application E NV& ' ; HE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' ''il✓1G S <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 S. Lincoln St. Cross 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)598-8117 <br /> C-57 Contractor Gregg Drilling Address 950 Howe Rd. City Martinez zip 94553 Lic#485165 Phone#(925)313-5800 <br /> Consultant/Sub Cntr ETIC Engineering, Inc. Address 2285 Morello Ave. City Pleasant Hill Lic# 624022 Phone# (925)602-4710 <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*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL#MW-1 A. MW-2A. MW-3A. & MW-4A 0 PRESSURE GROUT <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:?'____ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SCh. 40 TYPE OF CASING: 0 STEEL X PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '-33' TREMIE TYPE TO BE USED: 0 AUGERS -HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ](Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 60 ft.bgs If BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED none (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 OrdinancesZRuies and Regulations, and all applicable California State Laws. <br /> Signed x \ Title/Company�C Cww• `"Vn`� /��1�' ^ ^9 ,��C- <br /> Print Name M0.s e,w Date <br /> DEP RTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: qq <br /> WORK PLAN DATED: s-A2 W d <br /> Application Accepted By ` Date Issued 6 3 l v Area <br /> Grout Inspection By e4,� Date 13 10 Final Inspection By Date <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 /> -zR m l vtq "'> r$�1 o f Z 3 '93-7 !3(.�1 SR# 0 0 t I R � <br /> C-57—Z WC--V-WAIVER C-57 Letter of Authorization to sign permit--e�ncroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />