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GREGG DRILLING <br />ORIGINAPC:2/: <br />12/29/2005 17:01 9253130302 <br />DEC-29-2005 15:04 <br />COMMENTS I CONDITION .411171111111ft.--_. 1, <br />ACCOUNTING ONLY: AID If FAO; <br />RICO Dr PE CODES FEE INFo AMOUNT REMITTED CHECK* <br />L i. SRO <br />C-57 , WC / -WAIVER C-57 Letter of Authorization to sign permit - Encroachment dot_ ' <br />EHD 2947-001 <br />6a2/o4 <br />San Joaquin County <br />Environmental Health Department -RECIP,' Vki§--- ITE <br />(209) 468-3449 Fax; (209) 468-3433 Web: NVIVW.SjgOV.OreENehydli:OjN4 <br />ENVIRON MENT 005 H E ALTH <br />MITIGATION 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 A <br />.LF Well Permit Application <br />PERMIT/SERVICES <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to =instruct and/or Install the work described. This application is made in compliance with Son <br />Joaquin County Development Title, Chapter 9-1115,3 and the Standards of Son JoaquIn County Environmental Health Department. <br />Cross Street ihlibn City Afflife,A.- Zip Parcsfe FV41 71 ..t., -1...) <br />466Ph„eatell.15V <br />C-57 Contractor 60,, Address 19) fitly citypa ditrz, ziplea3 6honex N5)313 Pap <br />Consultant! Sub Cntr iff ti VirrafrittoressWOOr n41-i Pr- ity_eCEeVille. Lig:5$ Phonettj <br />Township Range Section <br />wo <br />i NEW ELL / CORINGigt, 0,EOPIROBE, HYDROPUNCH, HAND•ALIGER. OTHER) p DESTRUCTION (choose type below) <br />SOIL BORING o - a OVER-BORE DIAMETER <br />I • <br />WELL # <br />D PRESSURE GROUT <br />0 *Other <br />GROUT SPECIFICATIONS <br />COMMENTS:. <br />WELL Location <br />POWZrEnUrVI 194 AddreG 01)XtoO1g City <br />CIS Coordinates: x <br />+OIL BORING HAND AUGER GROUT SPECIFICATIONS 04-7- 61e-49U <br />TYPE OF WELL <br />B MONITORING <br />13 EXTRACTION <br />0 VAPOR <br />B AIR SPARGE/ OZONE USH POINT (GP or, CPTC7RO a UT SEAL PUMPED: a No (NOTE : <br />j OTHER: OTHER APPROX. BORING DEPTH <br />COMMENTS4, "CO6011 cri44- <br />Iftfyi;t0X7ING PROPOSED <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I horoby cortify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />Signed x. <br />Title/Company 0 1 C-C-R Ce 1Z5 1.0E-1-71—• (-)e-F-6G g. County es, d Fegulations, and all applicable califomia state Laws. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />4 1 <br />Print Name Coe Lc' Cti Date <br />DEPARTMENT USE ONLY <br />/2 <br />Application Accepted ey <br />Grout Inspection By <br />Destruction Inspection By <br />1NSTALLA7N rYPg <br />D HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />fl ML ID ROTARY <br />et atiSTEYVION $P_ECIFICATIONS <br />DA OF BOFLEHOLEY rj MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASINO: 13 STEEL 13 PVC D OTHER: Co <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 1:1 HOSE K <br />MAXIMUM FREE-FALL DEPT1-115 30') <br />Date <br />Date <br />Final Inspection By <br />Yes <br />Date issued ° 6 Nee 0 6 ,P117 <br /> sate___67C- -0 6. <br />D BOLTED TRAFFIC SOX or 1:1 STOVE PIPE <br />(if YES. list specifIcallons In cornment section) <br />TOTAL P.02 <br />DATE IT / SE RViatAt INVOICE