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11/17/2004 13:42 FAX 9166792900 URS-SACRAMENTO-GO 4002/002 <br /> 11/17/2004 13:49 916638 CASCADEDRILLIN� PAGE 01/02 <br /> 1.1,/16/2004 16:48 FAX 91(;(379 LINy-�11�:Kalri.i Vxu <br /> San Joaquin County <br /> Environmental .Realth Department SITE <br /> 304 Fast Weber Avenue,3rd Floor,Stocktorl,CA 95202 MITIGATION <br /> (209)4.68-3449 Fax:(209)468-3433 Web:www-sjzov,org/ehd <br /> UNIT IV <br /> Well Permit Application <br /> HON-REMNDABLE PERMIT MIPMES I YEAR FRONT DATE ISSUED <br /> APpllcation iR hereby made tv San Joequlp County for a Pew►to construct and/or instal]the work described. This application Is made In comprisrx�wilry gan <br /> Joaquin Courtly Development TMC,Chapter g-117S.3 And ft Standards of Sen Joaquin County l:nvlronmwtai Health Dopa,h. I. <br /> WELL Locatlnrt ��� C1 e_n5k!ro 1. I " i "saw-a- <br /> �., r.�s%58 SvaeC s�', tJ a ity _z1p 7`577'-4 Z``Pa <br /> PROPEA7 ,- l <br /> Owner l dress -P, <br /> C-67 Contractor Q Q 2 yr' <br /> �'^ dress-343'L O+rtc Girt tYn��C <br /> Ctty_r i 71p`t�adIA Phoncw �1/ <br /> CorralNtant/Sue Crttr '�S pc 3 A.ddreas x G..�C,.Iw p,-(CJ Cyty � � <br /> "+ l�._Phone# <br /> t3t3 Coordlmatc�:X ,Y TowrtRhlp Ra e <br /> � _Section <br /> ,�D���PERFORMtiD� <br /> `BrNE1M WELL!BORING (cPT,GEOPR086,HYDROPUNCH,HAND-AUGER,oTHf� p DESTRUCTION Choose <br /> OlI,BORING 9 { type below) <br /> fjIkVELL# I IY OVER-SORE. DIAMETER_ <br /> 0"hor 0 PRESSURE GROUT <br /> GROW SPECIFICATIONS <br /> COMMENTS; ,,� I J ��jf II r,___ <br /> INgTAL AMN CON TRUC `!c.r�O�S <br /> t IONITbRING O'HOLLOW STEM DIA•OF BOREHOLE V,ZS 0 MUL71PL=CASINGS U MULTI-LEVEL mN1/VELL CASING pIA; z r� <br /> (l EXTRACTION 0 AIR HAM"CR_REN CASINO THICKNES � <br /> 17 VAPOR p MUD ROTARY —5� � TYPE OF CA31NG ((5TEE1. g1f2VC BOTHER: , <br /> UT OF GROUT SEAL, TREr4le TYPE TO ae USEb: "HOA, <br /> 11 AIR SPARGEP OZONE 0 PUSH POINT(OP or cpT)GROCrf SEAL PUMPED; a Yes ra No (NOTE, MAXIMUM FREE-FALL DEPTH IS 3o-) <br /> 0 SOIL 80RING p HAND AUGER GROUT SPECIFICATIONS .�A/T �v <br /> p OTHER: __p OTHER APPROX.BORING DEPTH '--+0 "OLTED TRAFFIC BOX or 11 MVE PIPE <br /> COMMENTS: f <br /> CONDUCTOR CASING PROPOSED Of YES, f speeflcations In commnt e %&coon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 481rVCli t{fhlG HOURS NoTice REQUIRM FOR INSPECTIONS, <br /> I hereby certify that 1 have P red t Is a atlon and that the work will be done In accordan6e with San <br /> County Ordin as,Rul d R don nd all applicable California State Laws Joaquin <br /> Signed X <br /> T�1oM,gtnpany , �� a'��j��r <br /> Pant Nom <br /> Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a S 8 <br /> WORK PIAN DATED, <br /> Application Accepted By Date le8ued ` �� Q <br /> Grout Inspactbn lay ea l ?i <br /> Deatructlon Ing ethos Data 1 Filial Inspection ey Oate .3 D <br /> Dare <br /> COMMENTS I CONDITIONS; .7 <br /> ACCOUNTING ONLY: AIDS <br /> PAC* <br /> PE COMS FER INFO AMOUNT REIIfirrr p CHECK# <br /> RECD 8Y DATE PERMIT/SERVICE REgr�sT# INVOICE <br /> 35 d 1 yb?-Z R# j <br /> C-57— WC -WAIVER, C-57 Letter of Avtherizotion to sign Permit,,,,L Enero01' Irent doc <br /> EM 49 02oor <br />