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C-57 Letter of Authorization to sign permit roachment doc <br />sA pot- zt (3 <br />San Joaquin County <br />a mental Health Department Er <br />A' k . _ ,er Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd FE3 15 WIw.. ell Permit Application <br />ENVIRONMc-tNEVII.E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made giWattaVq;3IITS1hitYor 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 />6,/ifewe.4r fr <br />PROPERTY <br />Owner JAN coawr, Address /XV 44.2.-7740r1 /fri/ City 5.-/-74i/,04/ Zip fag Phone# <br />C-57 Contractor 14/4" 011917/m/ 0:41.SAddress 1570 ezuw/Wto P.1 8 City rAdfol/MZip fi;(1, Lia ;83— phone# (P.NY <br />4i0e440' Consultant / Sub Cntr jifr, Address 7"? e/Z grOe0" 125 -57e/g1City e:07e0gr*%, LiC# f(71"- Phone# ,-e/e•411-* e'w m-?s`? <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*)ESTRUCTION (choose type below) O SOIL BORING # ,OVER-BORE. DIAMETER /5' " <br />O WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />9 Nix L..7 <br />COMMENTS: fifit/-e <br />SITE <br />MITIGATION <br />UNIT IV <br />erm,vry 490wr- , Assessors WELL Location 51142 40,1# Vic#44, rf Cross Street/OW(4f /94/e- City "v4(-7°4/ Zip ff' Parcel# - 4.4r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />V MONITORING <br />APPfh 9 / 'VP DIA. OF BOREHOLE 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL 0 PVC 0 OTHER: <br />U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br />fl AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Alt:97 - c"--..-4,,e-W/7"- <br />a OTHER: a OTHER APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) ---- COMMENTS: \ r 1 t \i.I. l, I <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 />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x .1-‘4gt" .44(4_ Title/Company ..r/47 .:(4rO4'C/Ser <br />Print Name <br />DEPARTMENT USE ONLY <br />c SITE MAP IN UNIT IV FILE, ADDRESS: I- ( ( - • <br />WORK PLAN DATED: --4 t <br />iFee.e.r,r763114/411--ro.4;44 2-,r4 <br />Date <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />r Date Issued <br />.">1 AAAr Date 5-- Final Inspection By Date 4 ( to <br />Date <br />Area <br />COMMENTS/CONDITIONS brAf ,x1ru / c)--4311,1 gc rtj . +r• • .1 6 <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />i <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />'7 <br />SR# <br />-e I tkpLY <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04