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Signed x <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, a II applicable California State Laws. <br /> Title/Company e. Para 6 I itia hi flk•Air: DIAAAIP <br /> <br />Date Li • a 4/ <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment docaZ <br />San Joaquin County <br />Environmental Health Department j u N „ SITE <br />-I 304 East Weber Avenue, 3rd Floor, Stockton, CA 9202 2004 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.co.san-joaqu . '°'11*7- HEALTH <br />UNIT IV <br />MIT/SERVICES 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 />Sh , Assessors <br />WELL Location c)-0 5 , AL4rvf4. E-11 Cross Street j ct, c K-Con City c--/-pc/74-7 Zip s-.206, Parcel# I t/ (l c/ <br />PROPERTY <br />Owned C.---1/1-4d: nji.thri Keri.6.-144ddress d?C), 64)c-- 600f <br />C-57 Contractor itiOodli,Lii I 011744y Address V -1.1 D aox 33 6, <br />Consultant / Sub Cntr e‘occ,"‘„, c,1,/ Address )1 2S-(..) <br />City SiDck/Ori Zip c15.104, Phone# .2 Oq— 5166 -3a <br />City V,' 1 )c, Zip Y 57/ Lic# 7/0G74/Phone# 3y7-- y347 <br />h 0 rk PL city 6 0 Lic# Phone# 9/(0 - eS- 3 -O2' <br /> , Township Range Section <br />WORK TO BE PERFORMED: <br />g NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING # <br />0 WELL # <br />0 'Other <br />COMMENTS: s. <br />ESTRUCTION (choose type below) <br />'OVER-BORE. DIAMETER e <br />-a PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />, f _/14 — 3 — ti (AA- 0244k."4/171-- (71 cit7f - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING fl HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />0 AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />O SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />DEPARTMENT USE ONLY <br />Print Name Z/A A-66.0[44dgC) <br />SITE MAP IN UNIT IV FILE, ADDRESS: I 22' <br />WORK PLAN DATED: ci 1 3 0 <br />Application Accepted By <br />Grout Inspection By 14 Ar- <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br />1'14- 4^CA er-&-14r t-k) ..--e <br />ACCOUNTING ONLY: <br />I , <br />AID# FAC# <br />....... t.../ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT! SERVICE REQUEST # INVOICE <br />3 cOz— 040/ C(.9 I C( 3 Itt -7 ,1221 0 ti SR# 3 .:t9n <br />EHD 29-02-001 <br />9/30/2002 <br />GIS Coordinates: X <br />Date Issued 1-t j zz-/c) Area <br />Final Inspection By 01A4At" CI^ Date 0