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11/07/2807 12:01 9253130302 GREGG DRILLING PAGE 04 <br />NOU-07-2007 11:23 -RMBRIA <br />San Joaquin County <br />Environmental Health Depar <br />600 East Main Street, Stockton, CA 951 <br />(209) 468-3449 Fax: (209) 468-3433 Web; vrww <br />r Well Permit Application <br />�� 1707 9356RIGINAL <br />49 P.04i05 <br />e�{#✓ <br />�/'__7�; SITE <br />200j MITIGATION <br />FR; y�Nr a - IT IV <br />fi�CFc�Th' �� bg <br />NON-REFUNDABLE PERMfr EXPIPES 1 YEAR FROM DATE ISSUED <br />Application Is harety made to Son Jamquln County far a permit to construct and/or Install the work described. This application is made In complience with San <br />Joaquin County Development Title, Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Heath Department. <br />S AAW OMI �Vb N ftkA4AQr4t - Aseaesors <br />WELL Location Cross Stroot6alhSNS-k-bgsd Z;o S;20L Parce* t� A <br />P ROPER °""� W °'a' p R? ? $ 3 L (, <br />Cerner l dl, S� G �•dR) Address`/tS_ JV, �� Dpladrrl cltylt aklZ Phar�d 3t � <br />C•67 Contractor 1 <br />D&U16_AddreAe ttn►►IL Iia, Clty,�}�Zip1'4S'qic1 Phonos IZ 3 13 S�li'Q <br />ConsuftantrSub Cntr <br />CR - Addrelss \ A1kg1 g jKk j Ctty Uc?143�9 6_5� Phonet-76?Q3S 4 �`SU <br />WORK PLAN DATED: N <br />pr. <br />GIS Coordlnates• X <br />Y Township Range Section <br />/ - / Li-- % Area <br />WORK[ TQHE PFRFOMED <br />jPNEW WELL / BORING (CPT, GEOPROBE. HYDROPUNCH• HAND -AUGER, OTHER-) 9 DESTRUCTION (choose ype below) <br />Date 2 f i -08 Final In5pedlon By <br />p SOIL BORING <br /># 0 OVER -BORE. DIAMETER— <br />Data <br />WELL <br />- 17 a PRESSURE GROUT <br />Dr]" <br />j'Other <br />GROUT SPECIFICATIONS <br />Hof �nJfa dim z-/ z o8 <br />FAC* <br />COMMENTS: <br />PE CODES <br />PEr INFO <br />AMOUNT REMITTED <br />CHECK* <br />RECD BY <br />DATE <br />INVOICE <br />3so1 89.08 6q. 00 <br />TY <br />P__E.OF <br />INSTAII ji AT10N TYPE MSTRUC17ON_aM9E11CAT10Ns <br />C-57� WC_ -WAIVER_ C-57 Letter of Authorization to sign Permit_ <br />0MONITORING <br />'WHOLLOW STEM dW DIA. OF BOREHQLE) W"p MULTIPLE CASINGS n MULTI-LEVEL WELL CASING GIA; 2 <br />D EXTRACTION <br />0 AIR HAMMER/DRIVEN CASING THICKNESS_SiL6 `4 0 TYPE OF CASING: 0 STEEL )VVC 0 OTHER: <br />0 VAPOR <br />0 MUD ROTARY DEPTH OF GROUT SEAL y0! I(,7 TREUIE TYPE 70 BE USED. JrAUGERS a g'HOSE <br />D AIR SPARGE/ OZONE <br />a PUSH POINT (GP cr CP7)GROIJ7 SEAL PUMPED � es p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />D SOIL BORING <br />a HAND AUGER GROUT SPECIFICATIONS ��S _r_1 tt�.d i/f <br />0 OTHER: <br />APPROX BORING DEPTH S D If 1 i OLTED TRAFFIC BOX or -0 STOVE P'P <br />CONDUCTOR CASING PROPOSED (If YES. Ilst spec) mtlons In comment sedlon) <br />COMMENTS: <br />� <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 re rod thimPlicatIon and that the work wall be done in accordance with ann Joaquin <br />County Ordtne e , and all applicable Cal bmla Stato Laws. ���/G'�o 9 �n�j,�� <br />S gned x �� TitleiC o party �� b >1 i J�A'h / <br />>h -G <br />Name I . <br />Print NamDatm 1 , � � <br />) () <br />' <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />.2 D Chq Y <br />WORK PLAN DATED: N <br />er J. 2 <br />Application Accepted By V1 C -fa r 1 a IYIC <br />n Q y Data Issued <br />Y _h2-1 <br />/ - / Li-- % Area <br />Grout Insoectlon By. J; a oYi a L • lyl C erttdH <br />Date 2 f i -08 Final In5pedlon By <br />Vi h f: _./rifrfit�.Ra10 1 -��, -64 <br />—! <br />Destruction Inspedlon B <br />Data <br />COMMENTS/CONDITIONS. I <br />Dr]" <br />I ACCOUNTING ONLY: AIDS <br />FAC* <br />PE CODES <br />PEr INFO <br />AMOUNT REMITTED <br />CHECK* <br />RECD BY <br />DATE <br />INVOICE <br />3so1 89.08 6q. 00 <br />ZaoGL �_ 11-l'o <br />SR# 40105-2S78 <br />C-57� WC_ -WAIVER_ C-57 Letter of Authorization to sign Permit_ <br />Enc oc <br />END 29-02-401 WEB <br />9/1 vzooa <br />