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PAGE 02 <br />PAGE 02 <br />08/23/200E 11:25 9253130302 GREGG DRILLING <br />08/23/2005 09:5a 2n433 E.1-1D <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 4158-3449 Fax: (209) 463-3433 Web: wWW.sjgov.orWehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />2005 AUG 2I il tifif. <br />Appkation is hereby made to Seri Joaquin County for a permit to construct and/or rliitI,e work described. This applicatioSni P4 jTH <br />Joaouin County Devetopment Title, Chapter S-1115.3 and the Standards V San Joaquin County Environmental Health Dap mg R rAIME141*Lrl WELL Location 4 /3/' A c. A ut___Cross Street Afttj zip 7 524 lparcertt 1 <br />, <br />Owner 141•••01 T —Ic-re.4- Agrress 4144 Acr-c; A."4 Olty_,Siss sc.zei-iphaie# Adis. <br />PROPERTY <br />C-S7 GontractorroPilt 71-54.1atrag. 4460 /e4144/1 Cit,r/WAAtia•zp 4VSS31.1 YreSlePhong# 2S7-3(3.t.CPC <br />Sub Cntr irv-k ir-Ar*,4,-.4Loj g c.A IllerTSTIC <br />Address 2-10 'i -kisfS L1c# Phone#,-3.?. .2147 <br />GIS Cooremtrat.! , Y <br />WORK TORE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCK HAND-AUGER, OTHER') <br />SOIL BORING # <br />RANELL <br />rrOther <br />COMMENTS; <br />Section <br />o DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />n PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />Township Range <br />TYPE OF WR.L.I, LNS7_5: _trION LYTE CONSTRUCTION $e,ECITCATIONS <br />ti(44YONITORING AHOLLOW STEM DIA. OF BOREHOLE, ID 5 0 MULTIPLE CASINGS a MULT1-LVEL WELL CASING DIA; 7 <br />p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5e.:4 %ID TYPE OF CASING: EI STEEL ittf:VC S OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OP GROUT SEAL 2OL z..5) TREMIE 'TYPE TO BE USED: fr>tUGERS 0 HOSE <br />[1 <br />LI <br />B <br />AIR SPARSE/OZONE C PUSH POINT (GP or CPT)GROUT SEAL PUMPED; fl Vets No (NOTE: MAXIMUM FRE-FA L DEPTH IS SO') <br />0 SOIL ORING 0 HAND AUGER GROUT SPECIFICATIONS / " T4 ce" e....?" <br />El OTHER: n OTHER. APPROX. BORING DEPTH '15 )(BOLTED TRAFFIC BOX or g STOVE PIPE <br />CONDUCTOR CASIN PROPOSED it., .0 (if YES, llst speacatiorn in comment section) <br />00?11111ENTS: 45.cli"c•-e.el L.-•-ottri .I-; <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord;/ki A4iiks <br /> <br /> - • and p ations, and all applicable California State Laws. ..." <br />sgriexi :rot '1-7-.."./..ge • ." 61! 51 3 1 / /4- Title/DonIpanyceth:29:-/VIYea,A› <br />Print Name (Yarfr ' di e ,,- Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Of <br /> <br />DEPARTMENT USE ONLY <br />I po\x„.{54 .-4-ve • , Siv7c.t&dent.- <br /> <br />Application Accapted By „1,A-1-4-i.n.cot 1.- Date Issued <br />Grout Inspetton By t/tyv."^_c--- ‘-‘-,_ Date Pe1-42.. Final Inspeotion By <br />Destruction Inspection By <br />commeNrs , CONDITIONS: <br />Date <br />g•- 2_ 3 / o6 <br />t, -t_-w.' <br />Area Z-L <br />Date q <br /> <br />ACCOUNTING ONLY: AID# FAC# 7 C <br />FE CODES FEE 1N1i0 AMOUNT REMITTED CHECK# RECD SY DATE PERMIT / INVOICE <br />3 5-12 i $ .c-1. 0 , <br />103 5-0 8/43/0 6, SR# Li -3.. 9 Li t <br /> <br />C-57 WC -WAIVER c-57 Letter of Au-thor*zation to sign permit Encroachment doc <br />MD 29-02-0C I <br />6/221o4 <br />