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Nov 03 03 03:19p Hor rn Env. Inc <br />10/03/2003 13:09 7,094683433 FIFTH FLOOR <br />916 r1� 2172 p.2 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL. HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />rrQH- "UNDASLf~ PERMIT EXPIRES t yQAR AtOtM DATE ISSIJtb ' <br />Application ra nereny made to San Joaquin County to, a peiiait to conyhud andlor install the work daacribed. Thin apPhewion 4 made in 4Cmpl;Ance with Sen <br />San Joaquin County Enrirvmenla) Health Department, <br />Joaquin County 17evelopment Title, Chapter 9-1115.3 and the Standards of n <br />Assessor's <br />rr T <br />WELL Location ��3 G r II tpe Cross Street City ZiP -Parcebt f 7, <br />�i3 oG�O <br />PROPERTY Owner dares Coy �ZiP. M__QPhoneA��tSr 9DF' <br />u4LUA- <br />I RA city ZIp�A PtIone <br />C•57r4�D <br />b� <br />LlyZl <br />Consultant I Sub Cntr Adres!0 I <br />s. <br />GIS Coordinates: X Y Township Ran9e 9echon� <br />QT <br />WORK TO IRE PFRFOFRMEO: <br />` ► lEW WELL l BORING ( CPT, GEOPROBE, HYo PNC NO- UGEF{ OTHER) 0 DESTRUCTION (choose typr below) <br />irl S p OVER-SOAS <br />SOIL BORING # <br />D PRESSURE GR01}T <br />.-- <br />`a WELL; <br />Other Grout Specifications <br />COMMENTS <br />V <br />COrrJTPWC TtChr9r'EGYfICHTrol!?33 <br />TYNI: OF WELL INSTALLATtOIif Tl <br />Q MONITORING p HOLLOW STEM OLA. OF BOREHOLE MULTIP CASING57 Q MULTI LEVEL? 0 WiwLl GA51NG OLA. <br />Q EXTRACTION Q AIR HAMMERIOi41VEN CASINGTI-IICKtYESS • TYPE OF CA311 Q 3TEEL Q PVC Q OTHER. <br />U vAr'un �] MVU RV7ARY oePTH OF GROUT SEA TREMIE TYPE TO BE U3GD Q AUGERS p HOSE <br />t� <br />Q AIR SPARSE / OZOn� p PUSH POINT GIMTSEAC RUMIPEO:' Yes (TNo (aOTI�: M 4X1MUM FREE -FALL DEPTH IS 30') <br />'SOIL BORING d HAND4AGER GROUT SPECIFICAT S. <br />U 1 HNHTHE APP»: HORInrG TN n OOLTEO TRAFFIC 60x Oi Q STOVE PIP'Z <br />PROPOSED?y---y�-;� (IF YLt_a5. list specifications here)- <br />f <br />CO4r�lDUCTOR SI <br />_ Ir L ._ 1 /, _.��._.,. 31...w. ^t. 1n may•.._ 1' �- It,�i'll'Z`TT'i ►.K� r:A Od I1A�.1/mow <br />\` <br />NoT OFFSI E BORING t�EQU+RE AC E OR EN6ROACHMENT PE <br />I�MITS:' <br />CALL THE UNIT IV INSPECTOR .413-WORKING--HOURS-IN AUVANCE FOR -ALL REQUIRED INSPECTIONS_ <br />I hereby certify that I ha a prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinance t and Regalati0ns, 7rtdV1 appHGall 9tdt MM ' <br />SgrAd x ?itllelCompany <br />o'eo�� <br />3 �- <br />Print Nome _ �Qk f �-. �u' � Male <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: Work Pie <br />Application Accepted I <br />Grout InspDcrlon Bd� <br />Destruction In9pedipn <br />COMMENT3ICONOI <br />ACCOUNTING ONLY. i AID# <br />)ata issued 3 2003 Area�'4,:j__q_ <br />In.part,o-DY ��10 <br />PE COOED FEE1Mrb MMpIJNTrizMtTFEO" CF►fEk 1 REC•4 By� tiIFTL_ I•ERWTr SERVICE REQUEST * , INVOICE <br />iso t 84.00 89.00 Oo s 518 <br />B/z9102 <br />C-57_ WC-WATVEP C -57 -Letter -of Authorizatibri to sign perm,t�, <br />a <br />