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10/20/2004 ,16:25 91663856 1 „CASCADEDRILLING PAGE 06/06 <br /> San Joaquin Count <br /> N 0 V _ 1�qy#onmental Health Department 517E <br /> 4 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> • NVIR01�1046i�-mWax:(209)463-3433 Web:rvww.sjgov,org/chd UNIT IV <br /> PERMIT/SERVICEWell Permit AlpplicFyG;lon <br /> NON-REFUNDABLE PERMIT EXPIRES I YF-AR FROM DATE ISSUED <br /> Application Is heneby made to San Joaquin Counly for a pe mit to construct and/or install the work described_ This application is made In compliance wlttl Sat, <br /> Joaquin County Development Title,Chapter 9.1116.3 end the Standards of San Joaquin County Environmental Hoolth DepartmentAssessors <br /> WELL Looatlon ZZ�: S, n �eG t=b-Cr098 Street t—C:�cA 1 I,v city �o�1 Zlp ��� I Parcelm <br /> C <br /> PORwnerER G4- K _Addrem 0 � _5. {ra L City - <br /> --T tz 2LicJl-4 i�StoPhone#q t(��to�5 I t 409 <br /> C-57Coniractor Co�cc�cAe �1 tIhW�Address���3� ('v�cC City �Ziia;1 <br /> Consultant/Sub CntrV�Co ( < `S Address2�� ��4 'j CttycC[t � i Pnonc>x �l 16�6205�'J <br /> GIS Coordinates:X ,Y Township Ranga Section <br /> W._ORK TO BE PERFORMED: <br /> EW WELL,!BORING (CPT rPnaanaR,HYDROPUNCH,HAND-AUGER,OTHER') O DE§TRUCTION (choose type below) <br /> ZOiL BORING t' t _ p OVER-BORE, DIAMETER_ <br /> PRESSURE GROUT <br /> Q'04har GROUT SPECIFICATIONS <br /> COMMENTS: w elk kC, t <br /> TYPE OF MLL INSTALLATION TYPE CQN9TIiuCT1oN SPECIFICeMQNS /I <br /> 1ONITORINO X1 IOLLOW STEM DtA,OF BOREHOLE`65L? Ig MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: . <br /> !A D(TRACTION B AIR HAMMER/DRIVEN CASING THICKNESS �G LID TYPE OF CAS1N0: STEEL VC p OTHER: ___ <br /> p VAPCR p MUD ROTARY DEPTH OF C3ROUT SEAL TREMIE TYPE TO BF USED: 791-�UGERS Q NOSE <br /> Q AIR SPARGE!OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED:X''4es D Nv (NOTE: MAXIMUM FREE-FALL,DEPTH IS 30') <br /> A' OIL BORING 17 HAND AUGER GROUT SPECIFICATIONS_ <br /> d <br /> OTHER'_U OTHER APPROX,t30RINO OEPTH�nr Q ,_,fOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED _(if YES,list speciflcations 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 thig application and that the work will he done In accordance with San Joaquin <br /> County Ordi ccs, Rule end gu ons,and all applicable California <br /> /State Laws. <br /> Signed x <br /> Print Name�� ���N���T <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIDE,ADDRESS' �v15 S • e—r0 <br /> WORK PLAN DATED: 1 O ,. / // -1 / <br /> Application Accepted By Datelaaued /l123 lb Area 1`T <br /> Grout Inspection Ry Date N-1>21 Final Irtspeclion y 1 - Date <br /> Deatructlon Inspection By 08to <br /> COMMENTS/CONDITIONS: — — <br /> ACCOUNTING ONLY: AID# F q <br /> PF_CODES FEE INFO AMOUNT REMITTED CHECK# REC'D I3Y DA PERMI <br /> T/ CE REQUEST# INVOICE <br /> 3S0( �� �0 /SS SR5 6 <br /> C-57,_, W/ _ WATVER— C-57 Letter of AUlhor•izatton to sion permit—EnCroechMent doc_ <br /> EHD 29.01 -001 <br /> 6122104 <br />