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I , <br /> u, San Joaquin County [cM <br /> z ti Environmental Health Department SITE <br /> i` 600 East Main Street, Stockton, CA 95202-3029 V1 ,AY 0 R, 2009 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,org/ehd : I V <br /> ENVIRONMENT HEN- V <br /> 14 Ilk <br /> Well Permit Application PERMIT9'�.'gvlO <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. y,q <br /> Main St tAssessor <br /> lk7_26-422 <br /> wELLLocation 1030 South Olive AVeCrossStreetE `1✓ttVetStocktopp95215 t# <br /> Parce <br /> ti <br /> PROP,F! liam A. Scharf eRdd,,wR6792 LOS tOS ,s, CA 940 12 <br /> OwneYridres6792 Palo Hillsc;t�r. , p1 <br /> C-57 Contractor TEG 11.350 pier Park P1 . Rancbi? Cordovvp 9574-x# 7065"one#(916) 853-8010 <br /> consultands 4ZON Environmenta,, 4970 Windplay Icy El Dort�qp Hills,Ph {916) 939-2170 <br /> GIS Coordinates:X Y Township 1N Range 7E Section 56 <br /> i <br /> WORK TO BE PERFORMED: <br /> [KNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> (SOIL BORING#SG-1 through SG-5 0 OVER-BORE. DIAMETER <br /> p WELL# a PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING p HOLLOW STEM DIA,OF BOREHOLE 1 1JLTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS N/A TYPE OF CASING: a STEEL a PVC 13 OTHER: <br /> a VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL 5 feet TREMIE TYPE TO BE USED: GAUGERS p HOSE <br /> 0 AIR SPARGE!OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes wo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING p HAND AUGER GROUT SPECIFICATIONS Neat cement <br /> ©OTHER;_ OTHER APPROX.BORING DEPTH 5 f e e t t].BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N/A (If YE5,41st specifications in comment section) <br /> COMMENTS: Shallow soil borings for soil gasinvest.1gation. _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I her cert that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin Ices,RIM=gula=ons,and all applicable California State Laws. � <br /> r Project Geologist/Horizon Environm. <br /> Signed x TitlelCompany <br /> Print Name Ems A Krla Ck Date S/5/09 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT iV FILE,ADDRESS: rye. A < <br /> WORK PLAN DATED: Y <br /> Accepted By !'Amirn., <br /> Date Issued Area I � iiGrout Inspection By Date - Inspection By Date !2- <br /> Application 7 <br /> Destruction 4nspeckion By Date ! � <br /> COMMENTS l CONDITION$: S S `{ Y S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SERVICE REQUEST# INVOICE <br /> 36,105 g9,aD $q.v0 IG414y1 5-11-109 SR# QpSGG <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 />