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11/16/2007 12: 18 9253130302 GREGG DRILLING PAGE 02 <br /> NOV-16-2007 1142 CAMBRIP 1707 935 6649 P.04/05 <br /> San Joaquin County <br /> Environmental Health Departm CE�y,, SITE <br /> 600 East Main Street, Stockton, CA 95202- 0 AITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www,sjgov.?,j ��h 1 9 �0UNIT IV <br /> 0 <br /> c Well Permit Application 7 <br /> L V1 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ;MEP`T HE-ALTN <br /> Application Is hereby made to Smr Joaquin County for a permit to contlRltt and/or Inoll the workdekaaib�ed f)t}fv egin[ofila Meda in M.plisnoo with San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of Sari Joaquin County Environmental Health Department- <br /> WELL Location 77 77 n o jVf. 1AAVj Cross Sheat Assessors ;300 ' , <br /> �������D Parcels S�/t <br /> PROPERTYX51 �, �� � pq_d6 Cl Fr <br /> Owner f4N�<,� Address �L7 Q �f/tltil Zi honBi� �L 2.0 ZZ <br /> -- <br /> C-57 Contractor 1- - -J_e, 1'i i1uG�ddress s�t�� C . CIt�P �LIat Srb�Phonrn4) :- S <br /> Consultant/Sub Cntr t- Addressyq t2;U4fG�41r�f�Lily �Llcd Phone#7021?3C143.O <br /> U 14+--jz D <br /> GIS Coordinates:X 'y Township Rerve Section <br /> WORK TO BFC p6RFORMIED: <br /> p NEW WELL/BORING (CPT.GLOPROBE.HYDROPUNCH,HAND-AUGER,Will -OESTRUCTION (chawsQ type below) <br /> a SOIL BORING III a OVER-60RE DIAMETER <br /> a WELL 0 VPRESSURE GROUT 06r.r.�i <br /> a`Other GROUT SPECIFICATIONS �1 <br /> COMMENTS:___fA)p Pbr d e-"rA16tea SPC(2s knw''? YY1 W-14 w^lb. v'( w—lf) r<E.rheN.T` <br /> TYPE OF 11YELL INSTAL--LATIONTypE CObI{31RtJC710N 11PtsGFtC4TIONli <br /> Q MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINOS o MULTI-LEVEL WELL CASING DIA: _ <br /> o EXTRACTION o AIR HAMMER/DRIVEN CA81NG THICKNESS TYPE OF CASING: 0 STEEL al O OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL, TRE-Ml TO BE USED: U AUGERS a HOSE <br /> Q AIR SPARGE-OZONE S PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ll p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROJT SPECIFICATIONS <br /> Q OTHER: n OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED iir YES,list speclflcations in comment section) <br /> COMMENTS-, <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 virepared thl application and that the work will be done in accordance with San Joaquin <br /> County Or g ns,and all applicable Californfa state laws. / <br /> Signed x TiLWCompany �lijla <br /> Print Name Gl /'(� Datez/ <br /> /6 oro <br /> ov DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7 ;Oct <br /> WORK PLAN DATED:_r c`Lr-1(c_, J�07 <br /> Applloatlon Accepled ByD <br /> hd Com^ I <br /> I " <br /> ate Issued <br /> Grout Inspection By Oat ag Final Inspection By Dale <br /> Daatruction Inst len By Onto !z ") 1)7 <br /> _ t <br /> COMMENTS I CONDITIONS: .lig_- '. !�'? .j( <br /> ACCOUNTING ONLY: AID* FAC# <br /> PE CODES Ell AMOUNT REIIetTTED CHECK RECD BY DATE PERRimrri qull INVOICE <br /> SF <br /> (� �' 3 5 fix r,�� v�joZC�1�j <br /> C-57__-_ WC_-WAIVER, C-57 Letter of Authorization to sign permit--E-AcrnachMent_do4= <br /> EHD 29.02-%l WEB <br /> 9(11/2,007 <br />