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t 4L'e 1Y/ LVVS vv• 1J LV JYVV.JY-/-/ • .y .a •...vv.. --- <br /> �;2' <br /> WELL APPLICATION FOAM SITE <br /> MITIGATION 1 <br /> SAN JOAQUIN COUNTY <br /> UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) ; <br /> 304 E.Weber, Third Floor,3449 Stockton, CA., 95202 rG'U Y <br /> t209 <br /> ILE <br /> NON-REFUNI3ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct anftr install the work described. ThIs application Is made In compliance with San <br /> Joaquin County Development Title;Chapter 8-1115,3 and the Standards of San Joaquin County Environmental Health DepartmenL <br /> !� Assessor's <br /> WELL Location ilo I .S, [r-IYI c-A H s Cross Street Ck a VCYI 5+-. City s6ck�-0 n Zip 952.03 Paroel# <br /> PROPERTY Owner KeVIn BASSO Address IDES W.ckav{w WAJ City nclt�'oh Zip gS20i0Phone#lb-0o}zo"21-z <br /> '3 .33 �r{-z9ero+ IZgvicha 957+�Z C575S$.°179 <br /> C-67 Contractor W Cs F q a Addn:ss Sti t o rt7 City rord_o_y a Zip Lic# Phone# 5I o +`f+-117111 <br /> I55'y ge�� st- ca�ttio-r <br /> Consultant!Sub Contractor ]Ces Address tit m 1} F City oakla H Lic# Phone# Sia test'3zz v <br /> GIS Coordinates:X ,Y ,Township, Range Section <br /> WORK TO BE PERIORMED: <br /> I7 NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,FIAN -AUGER,OTHER-) DESTRUCTION( e type below) <br /> a SOIL.BORING,# VER-BORE � <br /> JAWELL# ISA W l 049 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WERE, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING n HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?1]YES EI NO W ELL CASING DIA <br /> []EXTRACTION C AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: I]STEEL []PVC []OTHER: <br /> (]VAPOR (]MUD ROTARY DEPTH OF GROIJ'i'SEAL TREMIE TYPE TO BE USED: :[I AUGERS [)HOSE <br /> p AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> []SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> U OTHER:_ IJOTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> `COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify t . ave prepa d t plication and that the work will be done in accordance with San Joaquin <br /> County Ordinanc , ules and Re ulati s,and all applicable California State Laws. II <br /> Signedx_ Titre company }.ax—1 +' rn c A i �-M Ar r In GQ� <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued )-2 —tea <br /> Grout inspection By Date Final Inspection By Date <br /> Destruction Inspection By. Date <br /> COMMENTS!CONDITIONS: <br /> EPECODACCOU <br /> ES FEE INFO AMOUNT REMITTED CHECK REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z ' 11 R# �3 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit--A,' Encroachment doc 1/25/02 <br />