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06/07/2005 08:55 5306628052 WDC EXPLORATION PAGE ©2 <br /> Sala 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.sigov.org/ebd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work dosorlbed. This appllcatlon Is made in compliance wish San <br /> Joaquin Cc"Development title,Chapter 9-1115.5 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Locaaon 12 F,Sb Locke $d Grow sbaer E(typ cuy taektktd zip 45231 paa�ro OSI 3 d I I <br /> PROP RTTyY <br /> ownerFktf4ow9 �'arAe.. QlodvclsAddress���pFl� Lrrlro ltd ctryLO k[fOrd Zip 237Phone*go4- 777.30'30 <br /> csscontractorWDC E ie >4;ft Addeasl.0• BOx 141 Chy2fmr- ziP-gMLIGM?83;2bphOM02Q6-473-307$ <br /> Consultant/Sub Cntrft:LJ.jr( Etiq Address 37:7 �• Pgf_¢' C1tyia (�aH.Lio>R Phone •2t(1.0�2 <br /> GIS Coordinates:X , <br /> Y _ .Township Range Section <br /> MRK TO BE PERFORMED' <br /> -•NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) Q DESTRUCTION (choose type below) <br /> QSOIL BORING 0 OVERBORE. DIAMETER <br /> �" Mr <br /> 01A - 1 <br /> ,r_z f a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> JIFF OF ft INSTALLATION TYPE �O,NST C C T ONS <br /> MONITORING I HOLLOW STEM DIA.OF BOREHOLE -LEVEL�r MULTIPLE CASINGS Q MULTI WELL CASING DIA: r <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESSSLIa 40 TYPE OF CASING: 0 STEEL I PVC Q OTHER: <br /> a VAPOR Q MUD ROTARY DEPTH OF GROUT 5EAL 1.0 36 TREMIE TYPE TO BE USED: N AUGERS Q HOSE <br /> Q AIR SPARGEI OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: [Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING aHAND AUGER GROUT SPECIFICATIONSQtt0&jS A! r2ca,th <br /> Q OTHER: R OTHER APPROX.BORING DEPTH 130 0 BOLTED TRAFFIC BOX or I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, Ilst specifications in comment aadion) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' ancas, Rules an egula//tiDDns,and all applicable CalHomia State Laws. <br /> s1� ,� I, rn Tale/Compam �iP� �l1LflL+:ev�G rn0.rAR LC— <br /> Pont Name Wey%y%e�I/L- B • 4 ea 4c. Date Ica . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED,:' ,f/r &LL 1 a C_-f3 /I <br /> Application A00oPled Sy Date Issued/n�X/dS Are■ <br /> Grout inspection By a-k� Flnellnspection By Date <br /> Destruction Inspection By _ Date <br /> COMMENTS I CONDITIONM <br /> ACCOUNTING ONLY: AID# FACS <br /> LPECODES FEE INFO AMOUNT REMITTED CHECK 9 RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,�7.ol I Eq - 89" (7Z3cj � R# Oo�/1(,2z <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 2M2-001 <br /> 6122/04 <br />