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10/10/2006 16:23 9253130302 GREGG DRILLING PAGE 02 <br /> 10/10/:,006 11:84 FAX 780 0426 DUMT & ASSOCIATES 9002/007 <br /> (*14,o6w <br /> U, San Joaquin County Environmental Health Department SITE <br /> < 304 Cast Weber Avenue, 3TO Floor. Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Wcb: www,sjgov.org/ehd UNIT IV <br /> Welf Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to Sao Joaquin County for a pormH to consiNct and/or install the work described. This appll6apon F made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Dapariment. <br /> w.^ / Assessors <br /> WELL Location A;2 4 'ldsT//4r ip Ike Cross Street L✓P City, -s t zip 94224- .Parcel# //704haa <br /> PROPERTY� ��tt // ,�(( le,2I/�. ` t�,.-' <br /> Owner_.1.Y<;..,._LkfamtGTa�L_--- Address ��jj -as�2 /�n�, City_eriP(.j�cPnOnEtf 'LsY�'..93'3/eyY'?�J <br /> C•57 ContractorclmVem DnIIm4 Address(-5> /`Vt _Clly lLZip-/TJJLIo honeff/r~3i�'� <br /> Consultant l Sul)Cru l.J(.9/,l/=1112- _Address doll-s" ,4LIC#_ <br /> GIS Coordinates:X !e' 357Y9. 56 .Y_2-1*'/G*/S 4gy .Township Range........_, Seclinn <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (ahDose type belnw) <br /> ,Q SOIL BORING If Q OVERBORE. DIAMETER_,_,_,,,__ <br /> WELL#, F__..-...._...,.--...__..... . .- 0 PRESSURE GROUT <br /> Q-Other GROUT SPECIFICATIONS_•-•____ <br /> COMMENTS' L.ns <br /> .Tye9 OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `$MONITORING Q HOLLOW STEM DIA.OF BOREHOLF/r'/' Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> ,Q EXTRACTION �Q A^^IR HAMMERrORIVEN CASING THICKNESSfZ,^TYPE OF CASING: p STEEL )'PVC Q OTHER' <br /> Q VAPOR Y`'UD ROTARY DEPTH OF GROUT SEAL S'SF TREMIE TYPE TO BE USED: Q AUGERS ;KHOSE <br /> Q AIR SPARGEl OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes0 No (NOTE: MAXIMUM FREE- ALL DEPTH IS 30'j <br /> 0 SOIL BORING QHAND AUGER GROUT SPECIFICATIONS 1r166/4" <br /> Q OTHF_R; n OTHER APPROX.BORING DEPTH96. !r '%�OOLTED TRAFFIC BOX or Q STOVE PIPF <br /> CONDUCTOR CASING PROPOSED (d YES,list specilleatlons In comment sealian) <br /> COMMENTS: <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 prep 4r d this appiiea ' and that the work will be done in accordance with San Joaquin <br /> County Ord% noes, Rules and Fl, one, n all applicable Califomi t t kY / I I`� <br /> �7 <br /> S lgnedX .••...- TIte/Company .1-s>- <br /> Print Name Y.' ivy 1 s..�'E'cs/I Date /U'I,,/GE. <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILA,ADDRESS: &Z j <br /> WORK PLAN DATED: <br /> Applination Accepted V AlaDale Issued b Area '7 .2 <br /> Grout Inspealian By <br /> Destruction inspection Dote <br /> COMMENTS r CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFOAMOUNT REMITTED CHECK# RECD BY GATE PERMIT I SERVICE REQUEST# INVOICE <br /> G S 14-�Z- / r� SR#00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doe_ <br /> LEND.^.9.01,001 <br /> 6117,/04 <br />