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11/14/2005 18:40 53066281292 WDC EXPLORATION PAGE 03 <br /> 11/14/2005 16:38 91640366 LFR • PAGE 03/04 <br /> 11/14/2995 10:23 2094683493 EHD PAGE 03 <br /> WELL PERMIT APPLICATION FORM LOP & SITE <br /> SAN JOAQUINN-COUNTY MITIGATION. <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EH0) UNIT IV <br /> 304 E.Weber,Third Floor, Stockton, CA., 99202 <br /> (;!09) 468.3449 <br /> NpNs��_ �JA9LE PIIRMfr E 111 1 mA�'FI;OM DA 18 m <br /> ApplNoven Is hereby made to Sen Joaquin County for a pemtd to donatruct ariNdr ln61ad&19 Work deSrt[I ThIS appllcatldn Is n¢tle In oompllanee vAN San <br /> Joaquin ONIMI O.�1013n,ent-11I Olmptar 8.11153 and fhd 34n6ardt of San��Jaa779,,d,n Cnunty Enuironmanfat HealthDe(--ayyri�mont�AeMm <br /> WELL Loc9Uan Z r oss Spee - -city Icy, ,Zip ZTJ1�1" POtCeMF <br /> —CIV l PharneN <br /> PROPOrtYCwneT Soy — C---gip <br /> CST CanlreoWr�J�.�..1l�sa,4��e�.o�' �,�l,g�d CttyXaP�,SL9A LIW�FnonaN ��. �a�� <br /> car®ulra,d;!ent,EMlt�yl_Fes. /41hr�(a r���r..Add,�a t o DI cn w�or,�:�(j - <br /> a15Coor9inat0¢:%,T .Y .Tommhip REnpa Seddon <br /> WQRK TQ BE PERF4t31ED: <br /> p NEW 1f L 1 BORING (CPT 0��ROPUNCK NAND-AUOER.OTNLK) p DEf TOv6RCBlO EN DIIAnnETER�hateW} <br /> SOIL BORIN�#I P D PRE98URF GROUT <br /> GROLiT SPEGPICATIDN3 <br /> Q"Cti,er <br /> COMMENTS <br /> IDMg LL iNSTALLATION_Tywe CQN$TRUCLMAR CIpCATK1�f5 -y <br /> MONITORING IOLLOW STEM DTA.OF BORkE1OLE lC.!JW MUI.TIPLE CASINGS BMULT7•1. V V'/ELLCASINGOIA.L -- <br /> n EXTRACTION )(]AIR HAMMr.R/ORIVEN CAS NOTHIC MESS TYPE OF CASING: n STEEL PVC p OTHER: <br /> LI VAPOR nWDROTARY DEPTMOFGROUT inIII w felI TREMIETI'PE70B5uar5t nAuolI p0_gFpvc <br /> n AIRSPARGJ CSON6 O PUSH POINT(OF a CP1)OROUTSF.AL PUN6�M Ygs 11 No (NOTE IAAXIMUM FREE�FALL DEPTH 13 30') <br /> p SOIL BORING DHAND AUGER GROUT SPECIFICAnON8• t I'+.VC -& - <br /> B OTFER, B OTHER ApPROM_BORING OEPTH J'Z,iii. II BOLTED TRAPFIC 9OX or 'X511'JVE PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,Ilstsppp9madna In o7nimM11$eddonl <br /> CONMENT:I: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 4$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 Ordin ,Rulw and R gufativ ,a all applicable Callfemi StateI Laws. <br /> slgnaa Tltle7Gompany e Q <br /> " <br /> ataS— <br /> "® DEPARTMENT ilSE OJ+ILY <br /> SITE MAP IN UNIT IV FILE,AQDRM: t <br /> WORK(PLAN DATED: N <br /> AJU <br /> App+;cason Ao aplad Br <br /> t I t,J Final hspecGon By Date <br /> Grant lnapactlon 6y +<I'K�'"u'� <br /> Dasiructicn Inspeoftm By We <br /> COlplypN'rS ICOrtpiTlONS• t <br /> ACCOUNTING ONLY: PION FAC# <br /> PECCpl:S FEE INFO AMOuNTREMITTGD CNECKR RECD BY RAT�gE P&RMITISERVICERl! U83T# INVOICE <br /> q.OI J10- r 111 1 IG illi'C7�„y SR,# (J'•, l- J <br /> C-!57_ WC ign permit <br /> =Wa _ _ EntroachmeyH da�� 9/30/02 <br />