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10/16/03 THU 09:20 FAA 925 363 7275 TERRA VAC NOR CAL <br />WELL PERMIT APPLICATION FORM <br />► IR01IM -WI AL HEAL111 SAN JOAQUIN COUNTY <br />VT qF?\"rF ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />a3 OCT 2 0 Phi : 0 f; (209) 468-3449 <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a pemM to constnict and/or install the worts described. This application Is made in compliance with San <br />Joaquin County Develcprnerd Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmerrtal Health Department. <br />WELL Location ZIT -2 7 (amuv n+cu t;,t�b�Ivdcross Stea n l� Cisors <br />�c� to_r�Zi P�c�et#�d '0�0 -2_%._ <br />PROPERTY <br />C-d7Cantract«_eStGr„ SQ,xGln Address 9-N,¢0,x -01CII 'WIwiZi st <br />CLLiCO l`l' Phoneo <br />Consultant / Sub Cntr 42 ,; r -f frc Vk c Address (')S ( m , �( 1, arty �LlcJk (o kV f 3�i Phone# �2S L3 - lj�.'L <br />GIS Coordinates: <br />WORK TO BE PERFORMED: <br />p NEW WELL / BORING <br />0 SOIL BORING #_ <br />0 WELL # <br />0.Other <br />COMMENTS: <br />Y <br />Township Range Section <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) <br />IYIC41 J,,E(( <br />DESTRUCTION (choose type below) <br />�j°°O�VER-BORE. DIAMETER <br />'II�SSHR�.GRAltT <br />GROUT SPECIFICATIONS <br />D <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J <br />p MONITORING (I HOLLOW STEM DIA. OF BOREHOLE <br />O EXTRACTION () AIR HAMMER/DRIVEN CASING THICKO MULTIPLE CASINGS � MULTI-LEVEL WELL CASING DIA: z �'` <br />NESS rA_ L� TYPE OF CASING: p STEEL AI VC 0 OTHER: _ <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL- <br />TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED:. 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: [l OTHER APPROX. BORING DEPTH 2-c) e 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in Cornment section) <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 propared this application and that the worts will be done in accordance with San Joaquin <br />County Ordinances, Rules a� ulatlons, and all applicable California State Laws. <br />Signed '- ` �� a Tdle/CarrtAany i -q e s t c r n Strata Exploration ,Inc . <br />Print Name Sylvic Jensel'1 rOIAA Oct. 17,03 <br />SITE MAP IN UNIT IV FILE, ADDRESS: � <br />WORK PLAN DATED: `6 - /O --.J' <br />Application Accepted <br />Grout Inspedion By- <br />Destructmn InaDechn <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />61 <br />Date Final Inspection By <br />Date <br />FAC# <br />/o -3 Arm L4 <br />N <br />PE CODES I FEE INFO AMOUNT REMITTED I CHECK N RECD BY fLLE IT / SERVICE REQUEST S INVOICE <br />35 ��. (� �1 - 3 <br />C-57 =AIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />5-2�F- Y6� zllc- Ze-.d I — a <br />-7 -a �� V6 <br />