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12/06/2005 17: 21 2094658773 SPECTRUM EXPLORATION PAGE 02 <br /> G2( . 6 • X006 5 : a.9Py L"iEh1t tal <br /> 11i22/2005 15:01 2994693433 END PWS 02 <br /> WELL PERMIT APPLICATION FORM r,-�SITe <br /> Uc L - 2-005I MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIFQ JPd :iv i ;I-ALI ENVIRONMENTAL HEALTH DEPARTMENT (EHD) ©UNIT N <br /> ICE" <br /> PER..�,! o_nV <br /> 30 <br /> 4 E Weber, Third Floor, Stockton, CA,, 95202 i <br />'r (209) 4683449 <br /> I <br /> NON�lEFUND�J,F_eF�RMIT IXPIRE31 YEAR FROM DATE IBBUfiO <br /> Appllcatlor is hereby made to San Joaquin County for a perrnit to construct andlor Insteit the work dasulbed, This application Is made In oomplianm with San <br /> Joaquin County DevelopmentnEle.Chapter 9-1116-3;and the Standards Of Sen Joaquin County,Environmental Health Department. <br /> WELL Loaatton III.�)r~xen4hk, Cross StreetCIy i 'Q �C)3)(p Assessors <br /> m ,1para®la <br /> PROPERTY Owner _N�U dU5 Atldless '��� II City lYOt('m bye �Phonet! 55'!II Z <br /> Csf Cont-a r ,�r !jAddracs ,Z,3U 6) I�t(uYtm f 1City S yffim z p J� DrUea�17�bRPhonsz/ q 1 71z <br /> ConstAlartl sub ConUaclO h• ' 1 ndaresn70,G llg$"I.'A'I�� City�_r_ �_UcA(0 (jZ) Phonnal tz04 P' 3 07rjt <br /> Sev,wce%.Inc.. J <br /> Gt9 Coordinates:X_.Y .Township Range Section <br /> WORK TO HE PERFORMED I( <br /> 0 NEW WILL I BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) XDESTRUCTION(chmse type below) <br /> a$OIL®ORINGM vER-soRE <br /> p WELL a II RESSURE GROUT <br /> 'OtAOr:_ Grout Specifications: <br /> COwElITS: l' 3 Will 6c-. Qycrdf';L rd., LudIS I � Z LO"I 1 bS- P11M LUO, ed. <br /> TYPE OF HELL INSTALLATION-7n E CON .(RUCTION SPECIFICATIONS I� <br /> ONITORING a HOLLOW STEM DIA Or BOREHOLE tr MULTIPLE CASINGS?(]YES t,.,,.� I I <br /> ,yD WELL CASING DIA: L i <br /> p EXTRA(:TION O.AIR HAMMERIDRIVEN CASINGTHICKIIESS TYPEOFCASING pSTEEL �VVG 901'HER• <br /> a VAPOR It MUD ROTARY DEPTH OF GROUT HEAL.�_a TREWE TYPE TO 8E USED: n AUGERS n HOSE <br /> u AIR sw,PuE n PUeh POINT GROUT SEAL PUMPED; p Yes O Nnb1(NE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0SOIL BORING 0HANDAUGER 13ROUTSPECIFICATIONS: Iye/OT� c` Ejnn P� <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 2S r d p BOLTED TRAFFIC BOX or O STOVE PIPE <br /> S EPFO W4 f Seer CONDUCTOR CASING PROPOSED? (if YES,list spedfleatlons hero)_ <br /> •COMMEIITS: c �fOI <br /> r; yr 1 eA <br /> TE: OFFSITE BORINGS RE VIRE AC ESS O ENCROACHMENT PERMITS. / <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> it <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordirwilfices.Rules and Regulations,and all applicable California Slate Laws. • 1/ ,, l f <br /> Signed x_ r ^TitlalCempany�i� [ X4 bi i '1-I ;r I r ell Td�� <br /> 1 1 ��J ' n <br /> Print Nam,- 1)r, l.NJ IT Doto z I <br /> DEPARTMENT USE ONLY t n o <br /> 31TE MAP IN UNIT IV FILE,ADDRESS: tit 11( f ,� �("1 S F 1�c���- L I■I I f <br /> WORK PLAN DATED: <br /> I <br /> Application Aeespted By UA-(A nrc.a__ Date las ued 12,jej I eT Area L-[ <br /> Grout Inepeotlnn By Ilam."... Dale 1 z- z5r S Inas IMPecdon Ely DaVJ <br /> Dr truollo i Inpr.oran By Date <br /> COMMENTS I OONornotm:Ar11AG S.TG eY fWe F-s- %!1rnL'([-r�rd'� <br /> ACCOUNTING ONLY: AID# e.lnr 1` <br /> PE CODESFt?E INFO AMOUNT REMITTED CHECK 1; REO'D BY DATE PERMIT ISERVICL REQUEST INVOICE <br /> S'az z-,va ' <br /> s�3 z r.t (33.7,0eq Sss ti IL 1criI sRaa oo N 5 S <br /> C-57-- WC,---WAIVER_„ C-57 Letter of Authdri2arien tei sign permit_Encroachment doe,, 1/25/(72 <br /> I' � <br />