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OG/08/2@06 16: 54 9253130302 GREGG DRILLING PAGE 02 <br /> nuu-I!21-GYJYJb 1h:34 :UGRO WEST, INC. <br /> ., 1 sea ass 0545 P.e2/e3 <br /> San Joaquin County <br /> N Environmental Health Department I I SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520 jo i065 MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web:www•sjgov ! hd UNIT IV <br /> l .r <br /> Well Permit Application <br /> �r.u;;::rFlil�cj <br /> NON•RrFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApPllcation is hereby made to San Joaquin County for a permit to construct andlor mstall the work desDlbed. This application Is irises In compllance with ban <br /> Joaquin Coury Developmont Title,Chapter&1115 3 and the Standards of San Joaquin County Environmental Health Department. <br /> catloo 23560 ICAS m RD Cross Street `5 Assessors <br /> WELL Lo <br /> city laaacr Zip PemgJ 73q-Izo •ol <br /> PROPERTY <br /> Owrar GOtsP. Gel! . oPeT*Irress 23506 KA;7SeW Rn Ctty_7pcy zi 95S <br /> p,_�PhoneM Zoo- 635-4iyl <br /> Cbl carliractdr�iQEAu r)4ttysA16 Addreos9SD Idtr,,r. QD ciy Nla.TrtuYalpQ�t5Sd LIa1 Pf'104phonevt425-�,�ie• <br /> Cenaullant l Sub Cnlr Twa Address 140061aAp CI Ow LIaM1 <br /> +^�7 b� vhoneAtS/OZ6B•046/ <br /> 019 Coordinates:X Y ,Townshlp Range section <br /> WORK TO BE PERFORMED. <br /> U NEW WELL I BORING (CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER') Q DESTRUCTION (choose type beloM) <br /> Q SOIL BORING x DOVER-BORE. DIAMETER <br /> 0 WELL a Q PRESSURE GROUT <br /> 'ff"OtMr_L ' CP GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE_OF WELL MTALLATION TYPE CON6TRUCTION 9PECIFICATION9 <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE A Q MULTIPLE CASINOS Q MULTI-LEVEL WELL CASING DIA; <br /> — <br /> 0 EXTRACTION Q AIR HAMMEPJDP,IVEN CASING THICKNESS TYPE OF CASING: U STEEL U PVC B OTHER; <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a NOSE <br /> • Q AIR SPARGE/OZONE jrUsH POINT(GPOP ROUT SEAL PUMPED:Wes ONO (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q 601E BORING 0 HAND AUGER GP,OUT SPECIFICATIONS (16AT C"f.NT <br /> Q OTHER: n OTHER APPROXBORING DEPTH So' Q BOLTED TRAFFIC BOX or B STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YES,list speclllceEena in cvmmertl section) <br /> COMMENTS: IzPArr5Rt0IE0S TE(sy PDttOWFAfre comptcrseA) — lt/i.r -T <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 prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Qles and Regulations, and all applicable Californiiaa'State Laws. / ����ll <br /> Signed X-Z72� TAlefCorrtpany ST1lF: F..or vef.R/r�.,16 ///I <br /> Pdrn Name MSCHAt3!^'b arw6 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS; d4 3 iy6 )L, <br /> WORK PLAN DATED: <br /> Appllcatlon Accepted By Date Issued q 1.4-10 b Area 6 Lt 9 <br /> Grout Inspection By IANn r e,... Darn Final Inspection By Date <br /> _Deatructlon Inspection By__ Date _ <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY; AID* FACS <br /> PE CODES LF111110AMOUNT REMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST INVOICE <br /> • ot9o1 {gq,00 ZIZZ.9 !tL 4 lob sR# L{ goOt(O. <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EMD 39-02-= <br /> w2vee <br />