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C-57 Letter of Authorization to sign permit Encroachment doc <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <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 Develpmnt TJtJe, Chapter 9:1 11N 4.the Standards ot San Joaquin County Environmental Health Department. <br />A Oltiv4-0-1Tc Assessors <br />WELL Location Cross Street L•,„ Sf. City c-mek.1-e_-.. Zip ci5-2.6.."% Parcel* !:" 5- 26(1 - 11 <br />PROPERTY PROPERTY <br />Owner 'Mr. Vr,../ /Mc 1-D A q 1 CC Address 34s -4,-,....ilt c-. city (4,...,14,, zip q s-2 (1/2 7-, Phone* (Zeig.) 416Ce - izco . t <br />C-57 Contractor I14,4<1411 aiii,,,, Address ri (i r-,n Ai 41.: A,4 City E,,ce_le.c.. Zip 1556 3 Lid* 0? 4 r7 Phone# (7 4 1-) -10 Li 0 <br />> <br />Consultant / Sub Cntr 4 r. a Address CZ 2:7 cl,4-...a 1)._. City Sitd iv-, Lic#6".„0 22.1 Phone* (zif,t1.-) Li &'..7 - Ir.) <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFCRIVIED: <br />a NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') <br />0 SOIL BORING* <br />WELL # <br />0 *Other <br />COMMENTS: <br />'DESTRUCTION (choose type below) <br />OVER-BORE. DIAMETER <br />0 PRESSURE GROUT \ GROUT SPECIFICATIONS -rye, _TITE I I <br />A E__ <br /> <br />SlT,E <br />MITIOA ION <br />04 DEC 33 4H <br />lYPE OF WELL <br />3(MONITORING <br />0 EXTRACTION <br />VAPOR <br />a AIR SPARGEI OZONE <br />a SOIL BORING <br /> • <br />a OTHER: <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: a STEEL a PVC 9 OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 9 AUGERS 9 HOSE <br />9 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 9 '!es 9 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a HAND AUGER GROUT SPECIFICATIONS _ <br />9 OTHER APPROX. BORING DEPTH D BOLTED TRAFFIC BOX or 9 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list s,pecifications in comment section) <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />a AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORK1N2 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 />County Ordinances, Rules and Regulations, and all applicable California State Laws. - <br />oc), <br />I <br />Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By r-4 <br />COMMENTS/CONDITIONS: Z---0 citi) *2--a 1.4)— tits i <br />ACCOUNTNG ONLY: <br />. <br />AID* <br />0 <br />FAC# <br />ii _ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY <br />_ — <br />DATE PER i - 'IC - -';'•-• ST # INVOICE <br />3CO2_ e>069 :06 O °g ,94 bz-o 6-i-K-- tz,1406 R#00(fr0q <br />Signed x Title/Com pany <br /> <br />-,--- /J.-- <br />Print Name ;5 ' Pr: Date 1.-- L I - <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Area 9 <br />Date Fin5Inspection By Date <br />Date ; • L-1 . <br />-WAIVER C-57 WC <br />El-ID 29-02-001 <br />6/22/04