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03/15/2006 11:29 5306766PI05 <br />03/15/2006 07:n5 20945, 33 <br />STRATUS NO CALIF <br />EHD <br />` WELL PERMIT APPLICATION FORM <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />OR 13 200a 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02/02 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />EiVV1 4N 't HEALTH NOW -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM QATE ISSU�O <br />Application IEPSWI VL cagUin County for a permit to construct andlnr install the work described- Tris application is made In compliance with San <br />Joaquin County Development Tito, Chapter -1115,3 and the Standard-. of Sun� Joaquin County Rnvironineutal Heahh De <br />partment <br />rewC ��� dSG G.Ff{reC ��• A <br />ssas-WELL Location ss Street Clcy cCkh,- ZipLOI parcel-0 <br />PROPERTY, �,i--ij <br />Owner t AGk Address as .I,-abF Avtrvlu't�1' City 21,Lk� zp75 26? Phone# 20�- �3.—93(�fp <br />C-,57 Contractor rr.&m Diiiq„ddreEEgSD glvk U,city Jtarkn zip 1 aL;c#03%5 Phone#oa . <br />Consultant1,9ui1Cn(r rrw.lUS itcn ° ,address D(�c1�C�h�l ( � °ty�+mrn�t �c��ic �� �5�`� Phanews�-%7i/O-�d6� <br />GIs Coordinates. X , Y <br />WQi2 TO 8 RFORldrzD- <br />L NEW WELL I BORING <br />0 SO(L BORING # <br />O[AN175P <br />(CWT, GEOPROSE, HYDROPUNCH, HAND-A[10EF:, OTHER”) <br />W ELL -- <br />SPECIFICATIONS SPECIFICATIONS <br />COMMENTS: ;Mw -? , Imp-]�� <br />Range Section_ <br />\DESTRUCTION (choose type below) <br />$OVER -DORS - <br />0 PRESSUR2 <br />. <br />0PRESSURE GROUT <br />GROUT <br />rCP_E_OF WELL INSTALLA-W TYPE C_fW-TRUCTION SPECIFRCAT11ONS <br />AAONITORING I�QHOLLCW STEM DIA. OF BOREHnLE1_ 0 MULTIPLIE CASINGS p MULTI-LEVEL WELL CASING DLA' <br />[] SYTRACTION j AIR HAMMERlDRIVEN CA51NG THICKNESS G- TYPE OP CASING: o STEEL XPVC 0 OTHER <br />VAPOR D MUD NOTARY DEPTH OF GROUT SEAL TREMIE TYPE TO SE USED- 0 AUGERS D HOSE <br />p NR SPARGE/ OZONE Il PUSH POrNT {GP or CPT)GROUTSEAL PUMPED; JKyeS Q No (NOTE: MAXIMUM FR E -FALL DEPTH IS 30') <br />Q SOIL DOPING p HAND AUGER GRCUT SPECIFICATIONS YLJ 4VM2 qlft&t - Yi <br />a OTHER !i OTHER APPROX- BORING DEPTH 9 BOLTED-MAFF[C BOX Q STOVE PIPE <br />r .� q CONDUCTOR CASING PROPOSED Ake (if YES/, list specifications in comme nL section) <br />COMMENTS:_ CSI( 5cd^-t Al 44-1n41,11-5j?5-1;- % I% -I&J _ WI 4,vLnlz�oara('�, S `m dL,�pNLIC i <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREemr=I`T 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 he done in accordance with San Joaquin <br />County Ordinances, R e and Regulations, and all applicable California State Laws,, Cl <br />Signed x A _ _�� _Title/ComPanY_- . _.. l2 e >`0�! S� ~ J f /SVi'roYt t^ �< <br />Print N2me i T w Date 3---(5-0 <br />SITE MAP IN UNIT IV FILE, ADDRESS: Z c-9 1:y —4-%A <br />WORK PLAN DATED; )oil 107- <br />Application'Accapled ek S��w` - Date Issue v rea_________ <br />Grout Inspection By Date Fnal inspection By <br />Date <br />De6tr c6om Inspgttiart!4- <br />COMMENTS <br />wCOMMENTS 1 CONDITIONS: <br />i ormsFdp <br />ACCOUNTING ONLY: Alb: <br />FAC# <br />.S <br />PE COPES <br />FEE INFO AMOUNT 1; MITTEC I CHECK # <br />REC'D BY DATE <br />PERMIT I SERVICE REQUEST # INVOICE <br />5-0 2_ �6�.�� ID�LZ VP ��ls`�,6 <br />� �I� <br />I <br />