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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ' �\)/J 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> fill hone: (209)468-3449 Fax:(209)488-3433 Web:www.siaov.ordehd UNIT IV <br /> ' JAN 2 1 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT HEALTH NON-REFUNDABLE PERMIT XHRES 1 YEAR FROM DATE ISSUED <br /> Appica8onngtnraoy/aC�5Wrae 3oaquin County for a permit to construct and/or Install the work described. This app kation is made in compliance with San <br /> Joaquin County Dew4opment Title,chapter 41115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> Well Location 1444 S. Lincoln StreetCross 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.67Coritracb, TEC Northern CA, IncAddress 11350 Monier Park Place City Rancho Cordova Uc# 706568 Phone 1916) 853-8010 <br /> Cwrouttant/Sub Cntr PSC Address 210 W. Sand Bank Road City Columbia IL Uc# Phone (618) 281-1543 <br /> ' OIB Coordinates:X 121.293579 ,y 37.936946 ,Township 1 North Range 6 East Sectlon 15 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLBORM6(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-GORE DIAMETER <br /> ' ❑WELL# k -t ❑PRESSURE GROAT <br /> ■'OTHER SC-1 through SG-7 f S4• 1 - tA"` GROUT SPECIFICATIONS <br /> COMMENTS: Seven soil-vapor borings, <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERWRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ' ❑VAPOR EI MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑Me (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Abanddnnbbrehofids with neat cement to surface <br /> g OTHER 1" borehole p OTHER: APPROX BORING DEPTH 6 Feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> for vap-3 sam—p7. CONDUCTORCASINGPROPO$EO (HYEs.Yt rParltrAUau In convnerA aedbn) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 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 an a ble California Laws. <br /> WLSigned , a.^4414.rn-1 TRIe(Conpany PSC / Project Manager <br /> Print Name Paul Anderson Date ) to gJcp <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �4 L rxel.elh S tv� <br /> WORKPVWDATED: O m <br /> APPLICATION ACCEPTED BY DATE ISSUED 12Llo!1 AREA SL L( <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ' ACCOUNTING ONLY: AID III FAC# <br /> PE CODES FEE INFO AMT REMn-rED CHECKS RECV'D BY DATE PERMRJSERVICE# INVOICE <br /> ' total 8°t. '0 S11-OJ "A-It 1114a1 I SR# 6 <br /> C-57 WC v -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> B10]9D1 tt/sa](NEa) WELL PERMm APP <br />