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it <br /> tl 03/15/ 2006 11 : 29 5305765005 STRATLIS NO CAI:- ` PAGE 02 / 02 <br /> 1 . 03/ 15 / 2006 07 : 59 20945 ;3 LHA PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> MAR I 0 ZQ05 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468449 - — -- -- <br /> ENVVNMEIf pff HEAICCTH NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE 15SUE0 <br /> Application I��'iCvS'� Yoaquin County for a permit f0 construct and/or Install the wocK descrlhed- This application is Made In CCmplianee with San <br /> Jaaqufn County Development Title, Chapter }1115.3 and th Stsndards of San Joaquin County Environmental Health Department <br /> WELL Location w� ' wa11C lltdlrlt a(� d05D f». Frim ssSireet Lvro1 $b, c;� Sj k�. zip 5Z� pa cgae s <br /> PROPERTY `` ,,�,y3u1 <br /> Owner s ) D1,1 Addras9 a�. �v'EI�+Y 1�vwlve}. �- Olty 5hxklmn XSp�PhonefE o21S J-�3 '�� R3GG <br /> C-srConvaetor ie x,11; .., Addre�e �50 Il<,U.e I�rf. qr elty orltn �/�ip�{ ,uc#'-IS5IL5 Phonal °i r_3t_3-SRoa <br /> ConSYltant I sub Cntr rt,,N5 iron fiddress t) C.AWf Crtnr � �a1M r✓m P.,/Eir to yS Phenen -67b-`r�D6 L�' <br /> GIS Ccordlnates' X - , Y_ Township _ — _ Range Section <br /> W RI YO 9 RFO fMEO: <br /> NEW WELL IISOKING (CPT, GEOPROBE, HYDROPUNOH, HAND-AUGER, OTHER') DESTRUCTION (choose type below) <br /> tr AMETFO 50(L BORING # OVER-BORE. <br /> %tVVELLk w - I r li1�I, 0 PRESSURE GROUT <br /> E Wother GROUT <br /> SPECIFICATIONS_ <br /> COMMENTS: - - �C riS�Cr,r '1 � ; n o,;r� • rwt tY+fW^3 bdKueTv jlAns �i✓tz' & W''"1 J ; 1024iiw"^ <br /> 7n(^ pE_OF WELL 1NSTALLABON TYPE CONSTRUCTION SP CIFiCATIONS <br /> "ONITORING HOLLOW STEM DIA OF BOR6HOLFT. 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> (I EXTRACTION tI AIR HAMMERIDRIVEN CASING THICKNESS2 TYPE OF CASING: (] STEEL XPVC OOTHER: —� <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL _ - TREM IE TYPE TO BE USED: Q AUGERS E HOSE <br /> 0 AIR SPAROV OZONE D PUSH POINT (GP or CPT)GROUTSEAL 'PUMPED; Wes 0 No (NOTE: h�XIMUMHF�Rry�E-FALL DEPTH IS 301) <br /> USOILBORING NANO AUGER GROUTSPECIFICATIONS ARa'I4Mt9o-CG 01 (f 5fv>'1w <br /> 0 OTHER N OTHER APPROX. BORING DEPTH qO lid n BOLTED TRAFFIC BOX df ri STOVE PIPE <br /> 544 <br /> � �,p Q 5 CONDUCTOR CASING PROPOSED nu (if YES, list specifications in comment rGotlon) <br /> COMMENTS:_ � Y'Ytn�C't . S,�ifl -(C%^awmz W/ cfjm za✓L5_f!A S �troV'L+C <br /> NOTE: OFFSITE BORINGS REQUIR5 ACCESS AGR�1111� O� CROACHMENT Pr=RMITS, <br /> 48 WORKINGS HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that i have prepared this application and that the work will be dane in accordance with San Joaquin <br /> County Ordinances, Rge nd Regulations, and all applicableCalifornia State Laws, 1 } <br /> Signed x Sr. 1t'�--� Title/company. ( '7eyGo� iS} � 5 '1Y5 FNViPovrt^m�.l'.r' � � 1 ( ) ) <br /> new.aRTMENr use aNl.v pate <br /> SITE MAP IN UNIT IV FILE, ADRESS : 2 e) <br /> WORK PLAN DATED._ 104� �✓//t <br /> Application'AccepWOy �,r� 1: .n coves Date issued <br /> Grout Inspection By to a n Dated(LQ �(z_Fnal Inspection 6y � r �` y /rz /06 Ali <br /> Date <br /> IDAM 6gn Inapsollan BY Date <br /> COMMENTS [ CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COPES FEE INFp AMOUNT REMITrEQ CHECK it RECD BY DATE PERMIT 1 SERVICE REQUC6T q INVOICE <br /> - <br /> C) � (z <br />