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GRI—1 DRILLING 92�7 30302 p. 7 <br /> Mar 15 06 01 : 25p p- 6 <br /> Com <br /> - -nth--� San Joaquin County <br /> Environmental Health Department SITE <br /> ,t 3rd Floor,Stockton C[195'LU3 MITIGATION <br /> 304 Fast Wvbcr Avcl i e, , <br /> 'p1, •t'",� (20'))4621-3449 Fan:(20)469-3433 Wcb:www.sjgov.or,,�,/cl1d UNIT IV <br /> Well Permit Application <br /> NON-RLFUNDAALe PERMIT EXPIRES 1 YLAK FROM DATE I55UkU <br /> Application Is herepy Insoc to San Joaquin County fora po,n,it to C0111M uct and/or Inc1.1II the work WO.cribed. Tl%appllratirxt is Inddc in nomplian(,*with Son <br /> ,Ioagturt County DcV0loprnant Title,Chapta 9-1116.3 and the SL,ndards of San Joaquin County ti nvironmental I IeA11h Lh:pwiment <br /> I q�^ V A5$ASW(s � 2-7C�-U� <br /> WELL IoCaGon— ...CS y i .r�C 1�4J p Yc nc7Cross 10b%:C1 W. (�,ah(•Lt/1tity—�t:�c"1 LO !J; ' Parmll�° 7- <br /> 1_. — — - <br /> PKOPERTY , ( cf Frp.c! t I a5 /(S <br /> (1WA01 ct1�•t Dcc_r�:1�«•��_�:'�Addrecc.��•l y.CSr_1(_: —.. City - �(OZIol`_.— Pl,o,,t#�_ _ _ <br /> 4tp_ <br /> G•67 Cortltu�or...•.�r"�`r1''�—�' •(!'�r� _Addras� �`� �"�• �"i' CIIYtV.rr"�Gl 7i �SS.S LidR_ <br /> ;11J c/air Rr•c.S( j(vrlty_ •ca.»-� Lic1Rcri`( Poona#?!�• y7.') F9 x�' <br /> OoltuultOnt/^Sub Grit,_ — <br /> GIS Coordi„etas:X•— ,—•Y— <br /> WORK TO 8E PFRF0 MCD- - - <br /> NEWWELL 1100 RIWG (cFrl',da-0PR6417,HYDW)PUNCH,I�A:uo-A`UkC�,OTHER”: D DESTRUCTION (d,(,n:�:.type below) <br /> $ ;OIL BOHINO k-,._.T-;L— _.— Q OV1 tt R<1hlF.. DIAMETCR <br /> D WL LL# — .— —. — n PRf.3";URE GROU1 <br /> d*Other — _ - — GH(x11 SPECIFICAl1ONS _ <br /> COMMENTS: _ .r).Let <br /> ��L� <br /> TYPE F WELL INSTA4la1I0N rYPC CONSTRUCTION S EC1rICA71ONS <br /> Q MONITORING u HUt I OW STENt DIA,OF BOREHOLE Z-c D MUL 11PLE CASINGS Q MULTI-LLVLL WELL CASING UTA: <br /> Q EXTRACI ION Q AIH I IAMMF.R/nRIVEN CASING THICKNESS—_ —I YPE OF CAaINQ Q STEEL Q PVC Q OTHER„ — <br /> Q VAPOR q MUD H01 ARY UEPTH OF GRnu 1 SEAL,-pSYS t_�r�Tt+l MIL 1 YPE TO nC USED: D AI A17Rf, OHOSE <br /> a AIR SPARGE/OZONL )KPU:;H POINT(CP oI CPT)GROUT 8 AL PUMPED Q Yor p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> �S011 BORING HAND AUGER cRoLiT SPECIrICA r IONS — <br /> n APPROX.8L)KINt DEf Tl i, Z5 - _p DO'_TEn TRAI ric ROX or Q STOVE PIPs' <br /> CONDU(:f OR CASING NR()POSE-D_. (If YES,list speciflgllont.in corriment sarylon) <br /> COMMENTS: -- - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4S WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County OrdinanceS,Rules and Regulations,and all applicable California State Laws. <br /> Signeu x_ . . _ — ---Title/Cornpaily_—. .— — — . .— <br /> Print Name - - .— ---- —. ._Cate_ — — <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: — <br /> WORK PLAN QATED:_ _ <br /> Application Acccpk;d By -- ——. — ,„,.— -- Date lsaue+d_._•__ -- --•- —Ar,a <br /> Date Fu, l Inspta —• -- <br /> C;rnut tnsocelwn Uy_ action liy Dat <br /> -- — -- — — �- <br /> Destruetim Inspection Uy Date <br /> COMMENTS/CONDI'r IONS: — -- <br /> ACCOUNTING ONLY: AIDC FAC# w„ _ <br /> PE COMS FEE INFO AMOUNT REMITTED CxECK# REC'D BY DATt: FERMIT!SERVICE RLQUF.SI's INYOICL <br /> C-57— WC. -WAIVER C-57 Letter of Authorization to sign permit„Encrodthment doc <br /> I-11U 29 0-nn1 <br /> bnaffllI <br />