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09/21/2007 16:14 2094683433 EHD PAGE 03 <br /> San Joaquin County <br /> ' Environmental Rea I th Departn90 �� <br /> 2 I 5� �~ <br /> 0.i 600.E.Main Strect,Stock n, CA 95202-3029 U �L SITE <br /> (209)468-3449 Fax: (209)468.343 Web:utivw.s ov MITIGATION <br /> 38 �flel + 820D7 UNIT IV <br /> ' Well PermitAp lication ENV;R0IVMENT8EALTH-- - — <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATEP1&WT&R11I0ES <br /> Appllcation is hereby made to San Joaquin Counly for a Pem�i to conr,trtldt an <br /> ' Joaqun County Development Title,Chapter&1115.3 and the Sbndards ofSa or install <br /> Co k described, <br /> Health Detion made In compliance with San <br /> WELL Location P I t. <br /> W 4 _ I44 _Cross StraetCSC City '� ZIP A-Inessom <br /> PROPERTY �P6d'E) ma <br /> OwyheeQy��y [a� Ifo Address l <14:1a4++!•il3 Ciry �A�.SPhene# 9 S -5S'tl8' <br /> C-57 Contractor rr, _,,,�,)},�„ Addm= a Fad, <br /> "-T-,�' II9Ro N-Go,l' a CIryZiPq�1 Lid# Phone;e��=�iS�- <br /> ConsDltant Sub Cntr Address kle <br /> GIS Coordinates;Xy621 y ,TOwrrshi <br /> Ramie Section <br /> WORK TO BE ERF-oRMED: <br /> G EW WELL f BORING Cl'T GEOPRO VpROPUNCH, AN OI UGE DT11ERry Q DESTRUCTION (choose type below) <br /> SOIL BORIN <br /> WELL? 11OVER•BORE, DIAMETER <br /> D*Othor 0 PRESSURE GROUT <br /> COMMENTS; GROUT SPECIFICATIONS <br /> m.I <br /> TYPE OF WELL INSTALLATION TYPE CONST UCTION p IFICgTIONS <br /> ' Q MONITORING Q HOLLOW STEM DIA,OF BOREHOLE <br /> D EXTRACTION [I MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> Q AIR HAMMER(DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL n PVC Q OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUTS 1. TREMIE TYPE TO BE USED: Q AUGERS <br /> Q AIR SPARGE/OZONE 0 PUSH POINT(GPorCPT)GROVT SEAL PUPA ➢HOSE <br /> ' >SOIL BORING Q HAND AUGER Q Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ry - GROVE SPECIFIC ATI NS <br /> B OTWER:��,�CDTHEA_`rs � APPROX.BORING DTH <br /> I <br /> COMMENTS: Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> UCTO <br /> CONDR CASIN PROPOSED (RYES,list specifications in comment section) <br /> _ <br /> 34 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS kGREEMENT OR ENCROACHMENT PERMITS. <br /> ' 48 WORKING HOURS NOTICE I <br /> SQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and the 1 the work will be done in accordance with San Joaquin <br /> County Ordinaes, Rulesaod gulations,and elf applicab a California State Laws. <br /> Signed x /47 '!- <br /> Pi <br /> �7—'--- _ <br /> rnl NameTIE Ompan`s I 111 <br /> Date <br /> DEPARTMEN USE ONLY <br /> ' SITE MAP IN UNIT IV FILE,ADDRESS: a"k Do - <br /> WORK PLAN DATED: <br /> Application Acc,;pted By - Date Issued R,I k Area <br /> ..._.. _..._... <br /> Destruction Inspection By Date <br /> ' COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FA <br /> ' PE CODES FEEINFO AMOUNTREMITTED CHECKS RE 'D BY DATE PE RMT I SERVICE REQUEST INVOICE <br /> Isis\ 91'0o > gq,o7 <br /> q .Lt SR#OCA`;2v/�� <br /> ' C- 4- WL WAIVER_ C-57 Letter of Authorizat <br /> E FID 29-02-ODlweb n to$igh parmif_Encroachment doc, <br /> Cv21a04 <br />