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V,. SAN JOAQUIN COUNTY j EN ONMENTAL HEALTH DEPARTI\�1T LOP 600 East Main Street, Stockton, CA 95202-3029D TION egcl oRa.Q Telephone. (209) 468-3454 Fax: (209) 468-3433 Web: www.s" ou WELL & BORING PERMIT AiPPLICATION OCT 15 2010 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATI - •NS f,Nl] REMEDIATION{ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEki"��Vj�'•'AJ,,��Ji'r4< 1$ppr HEA�LTH Application is hereby made to San!Joaquin County for a permit to construct and/or install the work described. This applicar0P1 TftR9A r T+A+�Ice with San Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 1030 S . Olive Afgss StreetE • Main Street City Stockton zip 95215 APN157-264-22 Property William A. Sharfe Owner 'Address 26792 Palo Hills 1�jyLos Altos ills, C&O;4022 C•57Contractok.11 Well Abandgi glt , 6626 Merchant City Diamond Springs, CAhA561 _ Consultant/Sub �„n Rn- Ck f o �Itt t 1--4�-� 'Pti� E1 '�Pn !BillablePartipuik Stop MarketAddress4567 Enter rise tcityF.remont; , CLIP 94538 Phone GI5 Coordinates:X3 7-9 5418 9 8 Y -121 , 235184 5te- - 8 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs FILE COPY ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparoe.Ozone!❑HAND AUGER GROUT SPECIFICATIONS O _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia Casing Depth: Boring Dia: COMMENTS: CEJ NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHEALL THATAPPLY #OF WELL(S)TO BE DESTROYED [30VER-BORE DIAMETER OFCK INCHES TO DEPTH OF 8 0 FT WELL Ids: MW-1 28tt Cement ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATION ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE g PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <1 COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS > hereby cert fy that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and 15 Regulations, nd all app'c I California laws. Signed Title/Company Prof ect Geologist/Horizon EnyironmE`C Print Name Em' 1 D. Kruck Date 10/14/10 ffr"'tC,', DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1030 6, 0 1 i'ye- AV e- WORK PLAN DATED APPLICATION ACCEPTED BY + DATE II ISSUED /O-IB -10 _AREA l�S9 GROUT INSPECTION BY �i ar, FINAL INSPECTION BY '��gh6a M,-IdOr fijut- DATE7d'28/0 I DESTRUCTION INSPECTION BY I A' Pr!'& ft r DATE I o- 2$ -/0 _ COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# iPE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY' DATE SERVICE RO# INVOICE REQUEST PR# s $ 122x rid 4+7f 7/ /0 -/9-/0 SR# 2,17 RO# 3503 366 .00 : �34G Q 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 0712$110 WELL PERMIT APP ,'7