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05/02/006 09:46 9253130302 GPEGG DRILLING PAGE 03 <br />ED'beNO perry►i+s `Fo <br />C R a f I6".In R+ei rt hair � _ ko I <br />w <br />1 mill"UNTY <br />y 2008 SAN VIRON ENTALHEALTHQUIN ODEPARTMENT SITE <br />N vIRONMEJNT HE p0 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />PERMjTvW (209) 466-3449 Fax: (209) 468-3433 Web: m m.siaov.oro/ehd UNIT IV <br />WELL PERMIT APPLICATION UNIGINAL <br />NON-REFUNDABLE PERMIJ EXPIRES tE AR FROM DATE ISSUED <br />Application Is hereby made to San Joaquin County For a permit 10 oonmruct and/or Install the work described. This application is matte In compliance with San <br />Joaquin County Development T)tle, chapter 9-1115.3 and the Standards of San Joaquin County Envimnmenlal Heellh Oepartmeni. <br />&'wq 7rlMce 1Yjc16 P10.2A. <br />jNeNl�beatlan Jazz FrewYnat iRd. <br />/' � <br />CioBs Street ^� rri�r_ <br />City <br />A6ae96ort: <br />Zlp X536{. Parcel # Se 4102paq <br />property <br />Owner 011e, jdkA 'SV _ <br />Addr"R 13( op M due+rltil <br />t <br />Rd. 's` City SQh Car 10 S <br />Zlp 94670 Phone # 1650-5%-615 <br />C.57 Contractor ., 1 Address 990 M'o1 �e Rd <br />CItY JgAr t;Ae X <br />ZIP��d_LIc N q BSr � s Phone 2 tS- <br />ConsultanUSubCntr_ <br />e 900 Mo11i4 Gt <br />S�+:k� City 611111UtIle- <br />Lic# S53Phone SID `Y&4-0796 �g0o <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASINO! 0 STEEL ❑ PVC ❑ OTHER <br />0 VAPOR ❑ MUD ROTARY <br />r^x:5ro- so- 170 <br />GIS Coordinates: X <br />Y Townchlp <br />Range _ Section <br />WRK TO BE PERFORMED: <br />ACCOUNTING ONLY:. <br />NEW WELLfBORING (CPT, OPROB YDROPUNCH, HANO-AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE 9ELOW) <br />ORING4 <br />Ej OVER -BORE DIAMETER <br />KOIL" <br />WELL <br />❑ PRESSURE GROUT _ <br />❑'OTHER <br />GROUT SPECIFICATIONS <br />COMMENTS; aP� <br />I2 _p_0_1yt <br />j■err <br />�u <br />TYPE OF WELL INSTALLATION TYPE <br />r■ i <br />CONSTRUCT19t4 SPECIFIC,f TIO <br />© MONITORING ❑ HOLLOW STEM <br />CIA OF BOREHOLE 0 MULTIPLE CASINOS 0 MULTI-LEVEL WELL CASINO DIA: <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN <br />CASING THICKNESS TYPE OF CASINO! 0 STEEL ❑ PVC ❑ OTHER <br />0 VAPOR ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL 3041 TREMIE TYPE 10 BE USED ❑ AUGERS ❑ HOSE <br />Cl AIR SPARGElOZONE t'US11 POI (LSP R CPT) <br />GROUT SEAL PUMPED: 0 Yea 0 No (NOTE: MAXIMUM FRET; -FALL DEPTH IS 30') <br />SOIL BORING ❑ RANO AUGER <br />GROUT SPECIFICATIONS <br />O OTHER: El OTHER: <br />APPROX. BORING DEPTH ❑ BODED TRAFFIC 13OX OR ❑ STOVE PIPE <br />CONDUCTOR CASINO PROPOSED (1 YER. Ual rpaolhallona In comment 10000) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certlty that I h p e llZfe cation and <br />that tho work well be done I accordance with San Joaquin County Ordinaneaa, Rules and <br />Regulations, II a Cell a a. <br />// <br />Signed <br />TRIef.Company <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS' I O 21 Z <br />-T <br />S- H 1 A iI Wa <br />WORK PLAN DATED: M is r_ r_ YI `7 <br />2 D /)',q <br />APPLICATION ACCEPTED BY I P 40 r^ r L, <br />j <br />PATE ISSUED S ,� AREA _J! 5 1 <br />GRouTINSPEC71ONBY Vi6ter'L&L.MePArtn4,A <br />5-27QaFIN�CTIONBY YWAY DATE S-i9�08 <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTSICONDITION9: A6%/ ° N e e L <br />(r -e in s2 "k e S 0!' b o r" ;'6A S <br />C-57 WC -WAIVER _. C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 1115N7 - <br />ENCRDACHMENTDOC <br />WCLL PL•RMrr APP <br />ACCOUNTING ONLY:. <br />AID #. <br />FAC N <br />PE CODES <br />FEE INFO <br />AMT REMRTED <br />CHECK # <br />RECVb BY <br />DATE <br />PERMITISERVICE # <br />INVOICE <br />3 <br />elf. <br />383.06 <br />/0341 <br />Ll�j_n <br />5-191C8 <br />SR#ap.5417 <br />C-57 WC -WAIVER _. C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />EHD 29-01 1115N7 - <br />ENCRDACHMENTDOC <br />WCLL PL•RMrr APP <br />