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101 ,2004 16:25 9166385611 CASCADEDRILLING PAGE 03/06 <br />w2o/2009 .1.4:27 VAX 91667929 Uli3'7iiL1<H1LL1IAl-1 �"" <br />San Joaquin County <br />nvironmental Health Department SITE <br />r. .z <br />East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 463-3449 Fax: (209) 468-3433 Web: www.sjgov,orFJohd UNIT IV <br />110* IENT HEALTH !,'Moll Permit Application <br />PLRf01T/SER\fNON•-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br />Application is hereby made to San.loaquin County fora parmlt to construct endlor Install the Work described. This sppIIcniIon Is made In compllance with San <br />Joaquin County Development Title, Chaptor 9-1115.3 and the Standards of San Joaquin County EnvlronmPntal Health Department- <br />Aaeeasors <br />WELL Loratlon BIZ �) « uCLA CrossStreot<'e ccs City SG1U O Zip Percel,.b7 y z�D� <br />PROPDR �t Address �U �D_x__C�1-L°�-.--CIty�4�r ci_Zlpq� J�Phon�ik �t�11 —�Ei I <br />owner u <br />C-87 Contractor <br />Consultant! Sub Cntr <br />�, CU � � dress `�-4S b C�u.�rcux>` U�t City Sa�ra>•�B �� Phone# G 16—G �-`�` Zo SLl <br />GIs Goordinatu; X <br />Y , TOvrn411ip Range Section <br />WO "FOR <br />EW WELL 1 BORING (CPT, QEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) �� VE RUCTION "7ER e type below) <br />L BORING W�C� ` n PRESURE GROUT <br />GROU SPECIFICATIONS <br />n other <br />COMMENTS: <br />TYPE OF 1NELL INSTA I-ATION_TY A CONSTRUCTION SPECIFICATLQNS 0 <br />�AONITORING `�iOLLOW STEM DIA- OF BOREHOLFS�-Q MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA_ 7 <br />U EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS SC 1A, `IO TYPI= OF CASING: n STEEL QVC U OTHER: <br />U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS n HOSE <br />U AIR SPARGEt OZONE o PUSH POINT (GP ar CPT)GROUT SEAL PUMPED: res U No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS <br />U OTHER: g OTHER APPROX. BORING DEPTH r1S I A 1 SOI OLTED TRAFFIC BOX or Q STOVE PIPE <br />CN CTOR C SING PROPOSED (f YES, list speclficatlons in comment section) <br />COMMENTS:- Q U <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 repared this plicatlon and that the work will be done in accordance with San Joaquin <br />County Of din lce5, Rt�le�fand uta is, and all applicable California State !_aws. /rA��r Aie;/'o /�/ <br />Signed <br />Print N <br />SITE MAP IN UNIT IV FILE, ADI <br />WORK PLAN DATED: -9 2 <br />DEPARTMENT USE ONLY <br />s: I t' l 2 Lu t --Q— -- <br />`i <br />Application Aecapted By Date Issucd / Z O res v <br />Grout Inspection 13y \ � . �. Date 2 Final Inspection By (�1�, ti,A, <br />t�C <br />Destruction Inspectlon B Date <br />COMMENTS / CONDITIONS: <br />q <br />ACCOUNTING ONLY: A1Df> <br />FAC# <br />PR CODER <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />RFCP gY <br />AMW <br />�3So (¢� <br />.�� <br />Od/0155 <br />jDATMEINVOICE <br />- <br />C-57 WC-WALVEP,___ C-57 Letter of Authorization to sign permit Fnc f�oc� <br />i✓14D 29-02.001 <br />6/22/()4 <br />cam_ <br />