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12!'06/2005 17:21 209465°773 SPECTRUM EXPLORATION PAGE 02 <br />GEc E• X005 5:49Pidi�llt �n;riro�7c.ntaI �3?-515 No X37? F. <br />1, :L; 22i`2005 15:01 2094682433 EHD PACE 02 <br />nC11�� ���� WELL PERMIT APPLICATION FORM <br />SITE <br />Ur — 0 2.005 SAN JOAQUIN COUNTY MITIGATION <br />ENVIROVECN-► NFALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT 1V <br />PERMIT/1D-VICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NIDN.REFI1NDg8},l���RMIT EJ(PIRE51 YEAR FROM DATE ISSl1Ep <br />Applicatlor Is hereby mode to San Joaquin Countyfor a permit to Construct andlar Install the wrork dRsorlbed This application Is made In compl;an06with Gran <br />Joaquin County Develropment Title, Chapter 9-1115.3 and the Standards of Can Joaquin County Environmental Health Department <br />•� 1 Aosessors <br />WELL Location III -I �e+-'t � • CrossSttrre-et CITY Q mil, <br />PROPERLY Owner s• C-tf 5, Addfea9 ' V ��` I I �'"1 IICltyI Ynp q �uaPhonet� �� 5 4112- <br />G S7 Cont actor r darass �� J I 1 Cifj < f Z;p3 �LiC 0 J �711oi�Phon A p 'r" U %I T <br />Consuttart I Sub Contraclo h' &I V • Addresca �U 7 G 11 5� )ID Ciry Lldl 1 Phon,�u ('2Q <br />44'6c(g Inc. <br />GIS Coord'riates: X Y . Townarip _ ^ Range $eoUon <br />WORK Ta BE PERFORMED; <br />0 NEW W7-1.1- I BORING (CPT, GEOPR09E, HYDROPUNCH, HAND -AUGER, OTH15W) DESTRUCTION (choose type bslow) <br />0 WIL©ORINGtt AbVER-50RE <br />Q WFLL RESSURE GROUT <br />'Other:_ Grout Spebficrdors; <br />COMMEtITS: r-=13 w; h bC. Qyordr; l l cd., _LuCft� J f µ ZZ Cts+ 11 <br />T1CP_E OF HELL <br />INSTAL ASIQ9--UP!e <br />Alfv'QNITC�RMG <br />0 HOLLOW STEM <br />D EXTRACTION <br />0 AIR HANMER IDPIVEN <br />Q VAPOR <br />0 MUt] r cirARY <br />0 AIR SPI,RGtE <br />Q PUah POINT <br />0 SOIL SC RING <br />0 HAWd P.11GER <br />0 OTHER: <br />0 OTHER <br />'COMMENTS: <br />CONSTRUCTION 3PECII=IC:914Ns <br />DIA- OF BOREHOLE `,, r` MUI.TIPLE CASINGS? U YES jjNO WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING, Q STEEL-19'PVC 0 OTHER; <br />DEPTH OF GROUT Cy5AL __ TfREMIE TYPE TO BE L'SED: n AUGERS p Hosrf <br />GROUT SEAL PUMPED; Q Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: �i�! tt 1 C; L Ib <br />APPROX. BORING OEPT1i 2 1; 0 BOLTED TRAFFIC BOX or 0 STOVE. PIPE <br />CONDUCTOR, CASING PROPOSED? (if YES, list spedllcatlono here): <br />J!.l.�Ll. - G• a- - • �r • , t � . ,� L _ ,rte. t ' � : -r 1' � r' �iL1 CO,�, <br />N'OTE: OFFSI E BORINGS REQUIRE AC ESS O'k ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinalices, Rules and Regulations, and all applicable California State Laws. f c <br />Signed x_ _Titta/Company I E'1 t CVr I 1� 1 r Cl7 f �� JL <br />Z (7 n <br />Print Name. Fin �'� 1 ---onto <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -;,00 <br />WORK PLAN DATED. <br />Application Accepted By ('("-N t"v%,%re;.I-- Date Issued I z 11 Ates �. <br />Orout. In®C edon By_ _ _ Date Fir+.n) Innpacdan ay pate_. <br />Degtructiu~ Inspmetlon By Date <br />0OMMONTS1t30N0ITlON&. 1JL xv.c a L, L 11 iLe (Lirr�tiCiG -2C/� <br />ACCOU'ONG ONLY: AIDS/ r' f,*, <br />PE CODES FEE INFO At11oIJNT REMITTED CHECK 4 RECD BY DATE RERMff 1 SSR INVOICE <br />s'c z Ec c,r <br />s s z 7� . r ��. cr. % C ( z/y CY` SRI! ` �' t� 19 <br />C-57 _ WC�-WAIVER_ C-57 Letter of Authori=etien to sign parml oc_ 1/25/02 <br />