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Jan 23 03 09:03a Horizon Env. Inc 916 939 2172 P.3 <br />b1�1iyz0e3 NS: 31 2094663433 FIFTH Ft,00R RTG <br />�CL,��L=;,i�,; WELL PERMIT APPLICATION FORM <br />JAN 1 <br />SITE <br />6 1003 SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONNIE:NT i4 ALT; ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />PERMIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 ^ ) <br />(209) 468-3449 f v <br />NON-REFUNDABLE PERMIT EXRI S 1 YE FRO DATE SSUED <br />Application is Hereby made to San .Inaquln County for a.Acrmit to consiruut and/or Install the work descn ed. This application is made in compliance with San <br />43gVin County Development 1 lite, Chapter 9"1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location Ll 611ty1(�r i�Cross Street Assessor's <br />Y. City Z;p Parcel#��� <br />PROPeRTr Uwner��/ Address�rj w.�MR <br />C -S7 Cuntracto CrtyA"-'�-_*. zip ? i30 Phonet� <br />;G/ Address 0 y <br />City Zip tS�l one#SS�T�3r0 <br />co+isu,Wnt fi N tltiv%amo,4.I Gnmr_dI_ Y -Lir alDl. .v <br />GIS Coordinates - <br />Township_ Range_ Section <br />WORK Tp BE PERFORMEU- <br />iVEW WELL /BORING CP EOPROBE, HYDRO AU*H, HAND -AUGER, OTHER') <br />OIL SORINGs <br />Q WELL <br />"Otl�rr: -- <br />COAIIMEfYT5'i} /tel .-.�i`T-Grout Specie <br />0 UESTRUCTiON (choose type below) <br />0 OVER -BORE <br />Q PRESSURE GROUT <br />TYPE OF WE" tNSTAt LATION TY('C r 9 STRVGT!ON SPECIFICATIONS <br />0 MONITORING D HOLLOW STEM DIA. OF BORCHOLE--.-L(' <br />Q EXTRACTfON AIR HAMMMUL1"IDLE CASINGS? ULl I -t EV[L7 a WELL CASING DIAYiQ2_� <br />ERIOR!VEN CASING THICKNESS <br />0 VAPOR B MUO ROTARY O"PTM OF GRVU 1 SEAL <br />p AIR SPARGE l Ozone Pusy POINT TREMIE TYPE TO BF USED: 0 AUGERS HOSF j <br />R GRourSrat t�urwf�Eu*es''"p- o,�t(NOTe_ MAXIMUM FREE -FALL DEP1�1 I'S 30") Q <br />ROIL 80RING 0 HAND AUGER GROUT SPECIFICATIO S. lw� <br />I] OTHER. J1 OTPER APPROX. 50RINI,; UtjPTHr - <br />�LQ F p 80LTCD TRAFFIC BOx or [1 STOVC PIPE <br />CONOUCTOR CASfNG PROPOSED?-_ y eQ ( If YES, list specifications here `�- <br />'COMMENTS: ) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV INSPECTOR 43 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify thA I have prepared this application and that the work will be done in accordance with San Joaquin <br />``County Ordi a Rules nd R ulwonS, and all applicable California State Laws. �n..,9. <br />15lgneo x `6 7317 `Title/Co np3ny� , �t &VV AI "',,e. <br />Fnnl Name C P k� n•t� �fL. _ i� /- i <br />SITE MAP IN UNIT IV FILE, ADOR <br />WORK PLAN DATED: 4 <br />TMENT USE -6 <br />Application Accepted By Date Issued_ <br />Grout Inspection By Dat,_- Finar Inspection By <br />Destruction Inspection ey ❑ale <br />COMMENTS i CONDITIONS; <br />ACCOUNTING ONLY: AID17 <br />p�E CODES FEE INFO 1 AMCUNT REMITTED I_ CHECK <br />RECO BY OATS <br />C-57 ✓ WC,` -WAIVER_ C-57 Letter of Authorization to sign permi <br />—Z j -03 Araaeh(� <br />P�j INVOICE <br />8/29/02. <br />Q) <br />O <br />l <br />r <br />