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10/10/2006 16:23 9253130302 GREGG DRILLING PAGE 02
<br /> 10/10/.^.,006 11:84 FAX 760 042 626 DODrX & ASSOCIATES 0 16002/007
<br /> g4F!1„� San .Joaquin County
<br /> Environmental Health Department SITE
<br /> �• '•< 304 Ract Weber Avenue- 3rd PIDoI'. Stockton,CA 95202 MITIGATION
<br /> (209)463-3449 Fac: (209)468-3433 Web: www,sjgov.org/ehd UNIT IV
<br /> Well Permit Application
<br /> NON.REFUNOASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> Application is ramby made to San Joaquin County for a permit to Construct and/or install the wort(described. This application LS made in cornpllBnoe with Sen
<br /> Joaquin County Development Tige,Chapter 9-1115.3 and the Standards of Sen Joaquin County Environmental Horl DepaKment.
<br /> // ,,,�// / Assess'Ora
<br /> WE LL Location/SI/ ur I/'&'A.o A,.- Cross Street L✓ T Clty S s - Zlp 9Slos .Parcell( A7L2.f1-$2
<br /> PROPEl ,fJJ� ./t iG1y
<br /> Own er_,7L.,,.r.LY�`IeR.GL��-__Addreuc
<br /> rla�✓ CI[Y�l-�7
<br /> C57 Contras lorQY'� J)n tl�Addres9_r0jf � pC[
<br /> _Cin/1Q Zip it✓.rL10'k 7o7 honeA �313-�
<br /> consultant(Sub Cntr t,J Gr�� - i�. _Adtlresa •aP✓J /sPT/ Clty ,.i,- I.Idi
<br /> GIS Coordinates:% 4"T47y9, g&' .Y �l�/6•VS,4'"y , rownshlp RenOe .__•,,,,�,,. Section
<br /> WORK TO BE PERFORMED:
<br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (Choose type natnwl
<br /> O SOIL BORING# D OVER-DORF, DIAMETER_,_,„__
<br /> 0 WELL*,„,”-_[_._..-.....-....,__.__..... . .- O PRESSURE GROUT
<br /> -Other GROUT SPECIFICATIONS_,__,_,_-__
<br /> COMMENTS:
<br /> XEA OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br /> "$MONITORING D HOLLOW STEM DIA,OF SOREHOLF./- a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA',
<br /> TYPE OF CASING: O STEEL VC 0 OTHER:
<br /> 0 EXTRACTION Q AIR HAMMF_R/DRIVEN CASING 7HICKNESSiSC�/j„_ 'WP
<br /> VC
<br /> VAPOR )K"UD ROTARY DEPTH OF GROUT SEAL e'5— TREMIE TYPE TO eE USED: U AUGERS 'XHOSE
<br /> 0 AIR SPARGFJ OZONE D PUSH POINT(GP or CPl)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE. ALL DEPTH IS 30')
<br /> 0$OILBORING UHAND AUGER GROUT SPECIFICATIONS I�✓� aF t d !& 9e./• ��/[ I-' - '/�'+'•-•z
<br /> 0 OTHER: R OTHER APPROX.BORING DEPTH �. BOLTED TRAFFIC SO% or p STOVE PIPE
<br /> CONDUCTOR CASING PROPOSED n (H YES,list speclllcations In comment cectlon)
<br /> COMMENTS:
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.
<br /> 4S WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS.
<br /> I hereby certify that 1 have pre pq rd this applica ' and that the work will be done in accordance with San Joaquin
<br /> County Ordi noes,Rules and Ft ons, n all applicable Call in t t I 3 G�."��.,�„L yt I I j LRS_
<br /> Signed edx / Title/Company , 6
<br /> rr77
<br /> Print Name `+ lig 1�C .+w✓I Date /6�Jf I4LL .�..._„
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FI ,ADORESS- /6Z�
<br /> WORK PLAN DATED: S
<br /> Application ACCRptP.d de
<br /> Data Issued�(I Arca-t'--/
<br /> Flnai Irtepectlon Date
<br /> Grazer IrepeOlion Sy __�.,,_. Date„-_1„L'�,(„ ,(?�- E'�' —
<br /> DesiruClidn Inspection Date
<br /> COMMENTS 1 CONDITIONS:
<br /> ACCOUNTINGONLY: AID* FAC*
<br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* Revo BY I DATE PERMIT!SERvIcE REQUEST# INVOICE
<br /> ,G T I A
<br /> 8s �J 1L / sDOY s"9
<br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_
<br /> ILEIO 9S-OJ,U01
<br /> Mal/OJ
<br />
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