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05/09/2007 13:38 6503283621 PITCHER DRILLING PAGE 03 <br /> 05/09/2007 HED 13109 FAX 2483433 SJC RED 0002/003 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ebd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County fora Permit to Construct And/or Install the work descdbod. This application Is made In compliance with San <br /> Joequln Cou4vpe�lopmem Tltle•Chapter 8.1115.3 and the Standards of San Joaquln county environmental Health Department. <br /> WELL LOcstlow. R 3 s00 /�o�SSoy moo( x Assessors `�1_"`aDr D l <br /> �tY's�G ZIP Parcel# - J <br /> PROPERTY G ia, [;•i2.. S'u 1 S t"r <br /> Owner°�-t.L±ss_ f�Y 6� kR Address �,y�.-cx .r te Cltyls.rl ap6�r +".')phorte#/s' •32�-- az,5.f" <br /> 0-97centeaorFItckaV (JT;111n5; address, ylca?k3t'�PhOnea6s0- z8-.`¢qto <br /> Consultant I Sub Crntr Address City Lit# Phones <br /> GIS C� mes:Xi,��j>;.g3i;3Z ,Y^—„ ..1p2C>c •CA TownshlP Range Section <br /> iioaKTOBePRFRr�€D:2YIt�� �Sj P3�.t 10 1.P,t"� 9�1t5,2v� 'Pl+N -)og£�•1rSFC�x ._lu`1<1k,5"a^ <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND•AUGER.OTHER”) n DESTRUCTION (Choose type below) <br /> n SOIL BORING s' 0 OVER-BORE. DIAMETER <br /> A1ELLs. -1 _ 11 PRESSURE GROUT <br /> COMMENTS: ( ~7j's, MW-l) GROUT SPECIFICATIONS <br /> TYP LLS 710 i TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLF_$'t b MULTIPLE CASINGS OMULTI-LEVEL 1NELLCASINGDIA: 1` <br /> OEXTRACTION nAIR HAMMERDRIVEN CASING THICKNESS--91S&L.-ipTYPEOFCASING: 0STEEL �VC 9OTHER: <br /> 0 VAPOR 41 MUD ROTARY DEPTH OF GROUT SEAL—_ � TREMIE TYPE TO BE USED: 0 AUGERS 'HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:'AAs 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> O SOIL BORING OhIAND AUGER GROAT SPECIFICATION <br /> _gt -=-c r�Cp ca.7'i <br /> APPROX,BORING DEPTH" til '�OOLTED TRAFFIC BOX or 05rova PIPE <br /> COMMENTS: CONDUCAB <br /> CTOR IN@ PROPOSED_4W c) (If Y14 list sRociOcafions In comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify th I ve prepared this application and that the work will be done In accordance with San Joaquin <br /> County OMina�nn . and Reotdattons.and all applicable California State Laws, <br /> Signed •�„ TtllelCompany Pitcher Drilling Co- <br /> PrmtName, y� 'h l3Derations Manaeer oat.• 5 9./07 <br /> _. / - <br /> UtPARTMENT USE ONLY { <br /> SITE MAP IN UNIT IV FILE,AD KESS: fir 'sc-1 A 3 0 2007 <br /> WORK PLAN DATED; 11 tG`.VNn )f l <br /> APplloatltn Accepted By 'T rL.Y,e) Data Issued-."/ 4167 <br /> Grout inspection By Date $' t S O Plnallnspecllen By to <br /> Destruction Insisedon By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# RECD BY bATE PERMIT I SERVICE REQUEST# INVOICE <br /> aq I 2`'j "; ? i '?�� c a�i9/n sR# say r 3 <br /> C-57•_ WC W AIVERY, C-57 Letter of Authorization to sign permit Encroachment doc <br /> /3rD 74-02001 <br /> 622M4 <br />