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C-57 WC -WAIVER <br />EHD 29-02-001 <br />9/30/2002 <br />C-57 Letter of Authorization to sign permit <br />San Joaquin County <br />Environmental Health Department JUN 0 1 2004 SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />ENT HEALTH UNIT IV (209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaclui4M tl/SERVICES <br />V/ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location /.,2 0 7 Ateiv•ove.. S1L, Cross Street dCeriSt9/4 Si', City SIDC.-0-011 Zip g.S:7-06 Parcel# /q7-3v47-1-9 51 <br />oq1/66-3_2(c,? <br />C-57 Contractor 4,02 14-41-d- Drai ....ci Address e 34)..1/4, 336 City 1A.4 7ip 996-7/Lic#7/0071 Phone# 70'2- 359 - y?co <br />Consultant / Sub Cntr JJ Li 6- e or C. e kicej Address / / "›-) er P/4 te City Liw-ci Ova- Lic# Phone# if ic 3 -8Z-22S- <br />PROPERTY J04/1, <br />Owner Jc.:TrIA .1/ Ae ,,„es Address p Eo..),- 67 00 City 571-0 a76k/ Zipi&4.2 Phone <br />GIS Coordinates: X Township <br />WORK TO BE PERFORMED: <br />)(4EW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />0 WELL # <br />0 *Other <br />COMMENTS: <br />Range Section <br />DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />[] PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />p MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />XAIR SPARGE/ OZONE <br />0 SOIL BORING <br />0 OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)(HOLLOW STEM DIA. OF BOREHOLE p 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: [] STEEL 0 PVC B OTHER: <br />0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br />0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 />CoLrity Ordinances, Rules and Regulations, pplicable California State Laws. <br />1 Itns <br />47/41//1/4' it/trook/4125. <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: et •17,-.5 <br />SITE MAP IN UNIT IV FILE, ADDRESS: ) 2_,e, <br />Signed x Title/Company <br />Print Name Date ._,A4r—.Qc/—ez/ <br />Date Issued <br />Date el 12.101 Final Inspection By <br />Date <br />y-z_77/0(1 <br /> <br />Application Accepted By <br />Grout Inspection By LA.‘21-4A-AAC-6.,-• <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />"3 co/ 10 f 00 lcik-( (1, Vizfry SR# 2g K