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10/18/03 THU�09:20 FAX 925 3. 1275 TERRA VAC NOR CAL FILE COPY _ <br /> WELL PERMIT APPLICATION FORM SITE <br /> NVIRONMENTAL HEALI II SAN JOAQUIN COUNTY MITIGATION <br /> prp.M'T SERVICE ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> 03 OCT 20 PM 1: 00 (209)4e8-3449 DV E . Wb X ZS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin Coolly for a pennit to construct andfor install the work desabed. This applkabon is made in mnpWnce vAh San <br /> JoaPin Courxy De dapnxml Tft Chapter 9-1115.3 and the Sle dards of San Joa pn County Environmental Health Departrrcrt <br /> WELL Location 21 b-�5 Co V I.).Of ydcross Street(r[n k Ian city a 11G fon Zip Pacew -690-2._ <br /> PROPERTY Owns �HQ✓!ems IrocQ. k Address P.tl, 90A (.et`/ ok6A • mn� Zpc/yS_X3 <br /> Cd7 Contractor i116J=r., 5d'.t tYn Address P.A.6ox LSA Cde,fA,kjIiticM _PhoMf <br /> Conaultentr Sub Crrtr ''rnVar- Address -1'1�(�.�,.��r .a.( 1,,,?4v Cuu.•r.� Lk reRo l3'� Immndrr12s-3tT-73TZ <br /> GIS Coordinates:X .Y ,Township Raga Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL I BORING (CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') /,�?ESTRUCTION (choseetype below) <br /> 0 SOIL BORING 0 XOVER-BORE DIA ETER <br /> D WELL# 'b PRESSURE GROUT <br /> a*Otter GROUT SPECIFICATIONS <br /> COMMENTS: A4 A /rt„me fi (� t/•r•+.C�"l) 2- +, r rl l r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING p HOLLOW STEM DIA.OF SOREHOLE-9 C 0 MULTIPLE CASINGS p MULTIA EVEL WELL CASING DIA <br /> D EXTRACTION O AIR HAMMER/:)RP./EN CASING THICKNESS d_kq .. TYPE OF CASING- p STEEL APVC D OTHER: <br /> p VAPOR 11 M(1D ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. D AUGERS D HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: 0 OTHER APPROX BORING DEPTH Zal, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ti YES,list sWftadons in care-ant section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby carWy that 1 have pre red this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan ulea a d egulatlons,and all applk:abie California State Laws. <br /> Signedx � �� 1' Z_ Ttiw/Compary western Strata Exploration,Inc. <br /> 03 <br /> P�Nwn Sy vie Jense DMe. Oct. , <br /> �ID'EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: c7 E) <br /> WORK PLAN DATED: 16-16--17 <br /> ApOicatm Accepted By - Date Issued— — Area <br /> Groot Inspe tlon BY Date Final In spectpn of <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT R MrED CHECK Y RECD BY I DATE PERMIT ISERVICE REQUEST# INVOICE <br /> 35o2- W 6' io•w SR96D 3 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit L&Encroachment doc_ 9/30/02 <br />