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12/08/2005 15: 48 20946587 SPECTRUM EXPLOR4)ON PAGE 02 <br /> 04lSan Joaquin County — <br /> �. <br /> Environmental Heaith Department SITE <br /> .4 304 East Weber Avenue,3rd.Floor,Stockton, CA 95202 <br /> MITIGATION <br /> 1 (209)468-3449 Fax: (209)468-3433 Web:www.,.jgov.org/ehd <br /> ,Illll'f IV <br /> a Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards Qf San Joaquin County Environmental Health Department. <br /> (L rr^• K' S ( AbSesso <br /> WELL Locaflon � ,� ��`C�i'oss Street lrt City � �E � Zip )2�Parcel# -67-21E6 <br /> PROPERTY coq C«r�e%tl <br /> Own, %;m l 5 6aAu S Address City1�a�Zipj'5 -c --Phone# z--1 `�4 4 b Z-`-,C <br /> C-s7 Contra:toEJLC7W,1Ot 'A6ldressa W r Ct A.Y4M ( .City L'T IP_t"`w LiCdt �/ honalk �� � <br /> t�1C. "Lt <br /> Consultant'Sub Cntr Ir— _ Address 17( 0 . (:.• Clbr Lrte 1~` Lic#1 !1�S-Phon 2 S ? -(•first <br /> g,2 C. <br /> GIS Coordinates:X Y Township Range Section <br /> :IE PER�FaRMEA: <br /> NEW W'RLL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER") ` DESTRUCTION (choose type be Ow)i a <br /> D 30t1.BORING* ilt'f OVER-BORE. DIAMETE <br /> O WELL* `in 0 PRESSURE GROUT <br /> 0 'QMar GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WOF 'ELL INSTALLATION TYPE CO.NSTRUCTION SPECIFICAONS Iy <br /> Q MONITOFING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTILEVEL WELL CASING DIA; <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS 5C N qw TYPE OF CASING: Q STEEL / PVC Q OTHER: <br /> Q VAPOR D MUD ROTARY DEPTH OF GROUT SEAL_30' TREMIE TYPE TO BE USED: GAUGERS 1]HOSE n <br /> Q AIR SPAFOE1 OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes D No (NOTE: MAXIMUM F EE-PALL DEPTH IS 30') <br /> Q$OIL ROF"1NG D HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER:_ 0 OTHER APPROX.BORING DEPTH -S 0, 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Ilst spedfleatlons in Comment salon) <br /> COMMENT71: _ <br /> NOTI:7-1; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. l <br /> I hereby mortify that I have pred this application and that the work will be gone In accordance with San Joaquin r <br /> Coun inances, Rules ulationS,and all applicable California State Laws. <br /> Sigam x TitterCompany ego f e r' 1' _ r <br /> Print Nerfte. Z <br /> DEPARTMENT USE ONLY S <br /> SITE MAI'IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:--ff <br /> Application accepted By 't. Data Issued Area <br /> Grout Inspelion By bate 2o Final Inspection BY Date <br /> Destruction Inspection By Date <br /> COMMENT3!CONDITIONS: <br /> ACCOUN'TtNG ONLY; AID* FACO <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 REVD BY DATE PERMIT I SERVICE REQUEST* INVOICE <br /> �{ - 0 l ! l7 �� SR# 00 15-1 <br /> k <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dot: <br /> F,xn 29.02-301 <br /> 6r22ro4 <br />