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11/23/2004_ 17:31 9166385611 CASCADEDRILLING, <br />11/23/2004 16:19 FAX 93-66792A <br />URS -SACRA. [ENTO-UV <br />PAGE 02/02 <br />Sn'n Joagatin County SITE <br />on "{ o <br />> Elnvirolnmenttal Health Department MITIGATION <br />304 East Webet Avenue, 3rd Floor, Stockton, CA 95202 <br />vov.or olid �ld �>1Q!l t ��( <br />• (209) 463-3449 Fax: (209) 468-3433 Web: www.sjg 8l 22 <br />�s�ro <br />Well Permit Application <br />NON.REFUNDABLE pFRMIT EXPIRES 1 YEAR FROM VA�E. ISSUED <br />115.3 and the Standards of San Joaquin County tnvironmenlal Health Department. <br />Application i6 hereby made to San JoasutnerCB tnty for a permit to construct and/or install the my described. This application is rt A9sesso Sp1lanCc w .n n <br />Joaquin County Davellop�meentTltto, Ch p Cdy �4��-Zip,_-Parcel# <br />Cross Streot� <br />WELL Location 1l LG^ ' - <br />PROPERTY. z-1-- <br />Owrler , a ,�j_ S Address X32 �° City 6 7 1 Phcnett S r ! I r1 <br />.. 5 ('j nL�" Gi Ctty �rcai+�L�P?� ZLlc�t �� <br />C-57 ConlraCtOr e M Address <br />-Fi' (j,_�1� w�,' u�r_Phono# 9 ! b - b �� 9 - Z.o <br />FYI a ddress � lty <br />ConRultant / Sub Cntr Uks Cc r' S� Section <br />(4IS Coordinates: X Y <br />Tou,ngnlp Range <br />WORK Tu 95 PEBE9_R_ME C UES`CRUCTION (Choose typo below) <br />t�EW WELL/ BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') Qp OVER BORE- DIAMETER— <br />Q SOIL 80RING # Q PRESSURE GROUT <br />�N LI" # �J - GROUT SPECIFICATIONS�_— <br />a *other <br />COMMENTS: <br />INSTALLATION TY_P9 CON I ICA710NS <br />_TYPE of WHI ZS MULTIPLE CASINGS Q MULTI-I.EVEL WELL CASING DIA: <br />v1WONITORING *AOLLOW STEM 01A. OF BORFHOL�_ VC OTHER: <br />Q EXTRACTION p AIR HAMMERIDRI�N CASING THICKNESS % k I(0 TYPE OREM ECASING: <br />TYPETO BE USED $ 5VIS3SO7) <br />STEF <br />Q <br />VAPOR Q MUD ROTARY DEPTH OF GROUT SEALS-- OTE: MAXIMUM FREE -FALL DEPT <br />Q AIR SPARGE/OZONE p PUSH POINT (GP or CPT)GROUT SEAL PUMPED: t9!Ye9 Q { <br />Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br />oLTED TRAFFIC BOX or [j STOVE_ PIPE_ <br />Q OTHER:^�Q OTHER�---r APPROX. BORING DEPTH sv If YES, list 5pecf5callonn In comment section) <br />CONDUCTOR CASING PROPOSED, <br />coMMENTS: w <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT <br />FOR INSPECTIONS. <br />OACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQU R <br />1 herebAord=cesl <br />at I have repay u hi ons, a all a nPa"', applicableCalifornia llSiate Lawsl be done . accordance with San Joaquin <br />County Rule andg O PPTitle/comptinySlgned x DatcPrint Na <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT 1V FILE, ADDRESS: <br />WORK PLAN DATED: Z <br />A.pPiicalion Accepted By CNS Date ISSued_ L, ��-:---A� <br />Grout Insvcctlon By �rn..rw� Dale Z Final Inspodlon By_ nA rwti bate 2 O <br />Destruction lm9pectlon By Dete <br />COMMENTS t CONDITIONS: <br />ACCOUNTING ONLY' AID# FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # PEC'D BY DATE PERMIT / Sl_RV1CF RED T i INVOICE <br />C"57— WC -WAZVEt___., C-57 Letter of Authorization to sign perr,iit` - l <br />CHID 29.02 -DO t deC� # 00 l <br />6/22JOq <br />1*W a.► - z I T <br />