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GRF -i DRILLING 925 '0302 p. 4 <br /> Mar IS nG 01z25p p. 4 <br /> tv6 t4 <br /> -6 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 104 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)465-34.)3 WL:b. vvww.s.jgov.0rg/C&d UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ApplicatIO(I it;h0ffty 111*WL'tu San J021,1vin(.*ounly for a pennit to construct oncuor imtall the work desi:ribad. Tilit;uppllcoliun Is Inode in rompliamm with Son <br /> jo,iquin CmjnIyL)uycIopM(!n1TiIlP,Chaptor 0-1115.3 ind thf,4 Siandaids of Sun Joaquin County Envirunnioiftl I 10,41th Deportmotit, <br /> %VV JG T'"­i Cross Strept"V'611 M"i L,kj_ city Tr���zip 7%3­1 Astessors<'0`0-Z-7 <br /> WEI.1 1.ncstion W j1ircr,19. <br /> PROPERTY ft'11A 7? SrPhor, <br /> Addrcrw, -Zip 4 <br /> (�ity r c,' <br /> C.!j7 ContirAclur 6 Address (4 V. ♦ city MA-tj"o-z/,P k* Phond ,)2S J 11 <br /> Consultant/Sub(141ir Arldross <br /> Phonet <br /> 019 Coordinales:X­ _.Townuhip —Range_ __Uction_ <br /> WORK TO REjjrRF0RMP15- <br /> ,WNEW WELL I BORING (CP 1,C.FOP Rom-,Hyr)ROPLI NCH,HAN r)-AU QE P,.OTHER") g DESTRUCTION (choose type below) <br /> la.iOIL BORING*. U OVER-tdORE. DIAMETER_ <br /> 0 WCI L* • -- a PIES SURE GHOUT <br /> a*Other— GROUT';PECIFIC:Al IONS <br /> COMMENTS:- <br /> TYPE OF wru.. INSTALLATION TYPt CONSTRUCTION q2_EC1Fj;ATI0N$ <br /> 0 MONROPING 0 HOLLOW STEM DA.OF 3ORCt1OI.E2Q MULTIPLL CANING 30, a UL11 11-1 r-VEL WELL CASING UIA:. <br /> a FXTRACTION 0 AIR I 1AMMEMDRIVIFN CASING THICKNrSS TYPtC)F(j\.-;1N(.,- OSTFtI, UPVC 0OT11177.13'­ <br /> nVAPOR 0 MUD ROTARY TREMIF.TYPL l0nr USED, GAUGLI-1-S. ..4,HOSE <br /> R AIR$PAR(W/OZONE KPt)OHPC)INT(OP orCPT)(,ROUTSF-AL pumpFr)- [jyeS 9 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> Jr,^.OIL BORING PMAND AUGER GR()UTSPECIFICATIONS... <br /> a OTI IE13: APPROX.[30RINU Utl I I H nOX ur U STOVE PIPE <br /> OTHER_ ­ .. _._ .. n DOI Trn TRAFFIr <br /> CONL)UCTORCA,131N(*.PRoposrr) _(if YES,list specifications in comment swL11011) <br /> COMMENTS:. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION& <br /> I hereby certify that I have prepared this application and that tho work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws- <br /> Sigroax ..­ — —— -- . <br /> Print Nooio <br /> DEPARTMENT USE ONLY <br /> SITE NIAP IN UNI I IV FILE,AIDURESS: <br /> WORK PLAN DATED: <br /> AppiloRtion ACcepted By._.___. j)nmIFfmed.-- <br /> (rout;nspedioo By By <br /> Oc'nruction Impentinn by Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNT[NO ONLY: AIL)*­ ---TA01 <br /> P[coots FEE INFO AT40UNTREANTIrr-0 CHECK# REC'D BYF0A#TEPtzKMIT I SERVICL REQUEST 9' INVOICE <br /> SR# <br /> C-57— WC---WA1VEP— C-57 Letter of Authorization to sign permit—Encroachment doc— <br />