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03/.15/ 2006 11 : 29 536676F905 STRATUS NO CAIPAGE 62 / 62 <br /> P. 09/ 15/ 2006 67 : 59 20946 33 EHA PAGE 02 <br /> B <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> U u ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> MAR 13 2005 304 E. Weber, Third Floor, Stockton, CA. , 95202 UNIT IV <br /> i' (209) 468-3¢49 <br /> ENV1RI)NME[ 1 [� H}I� KALcTI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 155UE0 <br /> Application }yoaquln County for o permit to oOnSVOct andlor Install the wofk deSGlbed- Tills application is Moe In Compliance with San <br /> Joaquin CountyDevelopment Ti9o, Chapter X1115.3 and th Standards of Sart Joaquin County Environmental Heahh Department <br /> Sw(fwall< r (( KIA1 qq <br /> YVBLL Ltlrition °� `dU SO �. Fr{m cross S4Pet �a,�w156, _CIry _ S1L'I, M. zip SLo l p eSSore <br /> P"CPERTY <br /> Er <br /> 11 1 <br /> -Owner k �AddresSa�. �, IN•a�fJe�+'�GI�Nr 56x154w. 7ip�,�',_.Phone# aDy93�� R�GG <br /> C�YCon <br /> tractor !t1146 <br /> Ad <br /> nt dra�eg50 11o�ua,.e I�rr.(, nn cryr,_,v11n znp / !{. Licn �fS51L5 PhonelF q'�'r313.5Roza <br /> Consulta / Suh Cntr 5 iMn ++' Address JJJDCAWi�Tn 1' I Gitr [ralMtim � �i[JFCA ys Phone# -�V7�-aD6Z <br /> GIs Coordlnates: X,_.-•,__,�, Y , Township Range Section <br /> WOR TOB RFO MED: <br /> u NEW WELL ! SORINQ (CPT, GEOPROBE, HYDROPUNCHi HAND-AUGER, OTHER°') )P5TRUCTION (choose type below) <br /> DIAME'rPR SOIL BORING # OVER-BORE. <br /> IiVELL « p PRESSURE GROUT <br /> 13 'Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS: 0yrd � I� 1 -MW - �p.l jyv p <br /> 1,!YEE_OF WELL &Ealt T10N TYPE CONSTRUCTION SPECIFICATIONS <br /> AONITORING HOLLOW STEM DIAL OF BOR6HOLE_$••77•„_, E MULTIPLL CASINGS Il MUL77-LEVEL W ELL CASING DIA' <br /> (I EXTRACTION 11 AIR HIAMMERJORIVEN CASING 7HICKNESS G TYPE OF CASING: O STEEL )a�PVG 0 OTHER <br /> a VAPOR D MUD ROTARY DEPTH OF GROUT SEAL_ TREMIF TYPE TO BE USED: p AUGERS 1] HOSE <br /> p AIR SPARGE/ NONE II PUSH PONT (GP or CPT)GROUTSEAL PUMPED: 'WU 0 No (NNOT�AAXIMUM FR IE-FALL DEPTH IS 301) <br /> Q SOIL BORING () HAND AUGER GROUT SPECIFICATIONS <br /> 9 OTHER,, ti OTHER APPROX, BORING DEPTH n BOLTED 1RAFFIG BOX Af 11 STOVE PIPE <br /> ��''ti�i� [[ '' ..��,,pp & 441= j <br /> � qs I CONDUCTOR CASING P <br /> I -ROPOSED iw IT YES„ list specifications in comment section) <br /> COMMENTS:_ �wr� ,Jcyy ADIr'tint�t j _ 53g-41G^a6bPz W7 s1/ keac _fStem <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREPMEN'T OR 9NCROACHMERNT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I <br /> I hereby certify that i have prepared this application and that the work, will be done in accordance with San Joaquin <br /> County Ordinances, RJB{Je and Regulations, and all applicable California State Laws,1 l l� <br /> Signadx 5 (�p I✓ 7iae/Company 6 ( 0 (05i5T ' 51YLXL Grti/iPoVlvncH.leA' �w,.f <br /> PrlrrtNane _ . Jcat"C t T W dT Dete <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS : Zy SO �1 Sw.o .J I }�,�(�{� r <br /> WORK PLAN DATED, 10I <br /> If <br /> Application 'Accepted By }�,;iI! ynU.( Date Issued 3 /s (OL, Area <br /> Groot Inspection By _ Date Final Inspection By6 <br /> Data <br /> 0astmetlon Inspgction B� Date <br /> commit S ! CONDITIONS: <br /> ACCOUNTING ONLY: AIDS FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK it RECD BY DATE PERMIT ! SERVICE RUQ'JCC' T p INVOICE <br /> 3sz,Z 6a. o � i0 '3zZ- V? � s��� s2 �{ ro I � <br /> 3so3 , <br />