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08/04/2008 09: 59 9253130302 G:�EGG DRILLING PAGE 02 <br /> AUG-04-2ooe 09: 13 '11�MBR I A •..W 1787 935 6649 P.02/03 <br /> San ,Joaquin County FILE <br /> Environmental Health Department SITE <br /> 600 Fast Main Street, Stockton. CA 95202.3029 MITIGATION <br /> \j `209)468-3449 Fax:(209)468-3433 Web:www.sjgov.crg/ehd UNIT IV <br /> Well Permit Application — <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O <br /> Application Is hereby made to San Joaquln County For a permit to construct and/or install trio work doacribed. This appllcailon is made In compliance with Ser. <br /> Joaquin County Development Title, Chapter 9-1115 3 and the Standards of San Jooquln County Environmental Health Department <br /> D -1 � J A�cesaors <br /> WELL Loeatlo1267 �i�_� <br /> n ,�r#_ '6/�Cross Street r �' <br /> r�"' �CJry Zip Parce{it 11 3oY2/ <br /> e 42 <br /> Ow41_ .. 1-5 _ _ Addrese ��, V. ��}n u"`� rClty_ 51k,/'j,.—ZIP gS Pnnne}n, /`A <br /> 0-57 ContractorA dress Chyrj��' -'11Zip•9y��t- YR5/6Phoneit <br /> --� A3yr�.i S ,�,5.-.!r Z3 O <br /> onsu,"n r Sub CntrCy rS�s c-� ne"s � Address 19 Y`1�i ���ip��City :y.cr�. Lids /�/.a Phone# <br /> GIS Coordirates: X 3t. Q7t) Y —tV -315 Township Range SAetlan_, <br /> MAK TO BE PERFORMEp: <br /> NEW WELL I BORING (CPT,GEOPROBE.HYDROPUNCH,RANO-AUGER,OTHER,) Q DESTRUCTION (choose type below) <br /> 0 SOIL BORING r Q OVER-BORE, DIAMETER <br /> OVVELL* -5 -4Z PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIQN APECQC� TIONS it <br /> ,,"ONITORING HOLLOW STEM DIA.OF ECREHOLE_,? Q MULTIPLE CASINGS Q MULTI•LEV!:L WELL CASING DIA <br /> Q EXTRACTION p A1R HAMMER/DRIVEN CASING Tl-11CKNESS-� rTYPE OF CASING: Q STEEL XPVC Q OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEATREMiE TYPE TO SE USED: kAUGERS n HOSE <br /> Q AIR SPARGE)OZONE n PUSH POINT(GP or CP7GROUT SEAL PUMPED: Q Yes Q No ( OTE:MAX[ UMFREE!-FALL DEPTH IS 30') <br /> Q SOIL®ORING Q HANO AUGER GROUT SPECIFICATIONS Pos �«h <br /> 13 OTHER- [1 OTHER APPROX BORING DEPTH Y S ^,�ROLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �c7 (N YES,list specifIcatlons in comment Sedlon) <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 hay pr pared this licatlon and that the work will be done in accordance with San Joaquin <br /> County Ordi n i and all applicable California State Laws. <br /> Signed <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: p <br /> WORK PLAN DATED: Q <br /> AppOcatlon Accepted By Dole Issued Aroe L/ <br /> Grout Inspection By Dale F nal Inspection 8, <br /> Dectruol on Inspection ey Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AJOap FAQ* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK f RECO BY DATE PERMIT I SERVICE REQUEST* INVOKE <br /> 3501 <br /> 2. � ? SR! <br /> C-57 =_ WCWAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> GHD 29-m-ooi WED <br /> 911112007 <br />