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C-57 Letter of Authorization to sign permit Encrcrachmen C-57 <br />EHD 29-02-001 <br />6/22/04 <br />-WAIVER WC <br />San Joaquin County <br />Envii imental Health Department <br />SITE <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />MITIGATION <br />UNIT IV <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />WELL Location SLIO ki-tAt4Xi4i.11. f Cross Street G . Doi- 51: City 5fLtettik Zip 4152P4- Parcel# -/bV/O <br />Assessors, <br />PROPERTY <br />Owner Ski,1-TtAtulaereltilii QuAddress1). V. 12-57 City siv kir Zip qc.2C1-- Phone# <br />C-57 Contractor CilifilAn. i-l-t4 /1-14C.Address 61 56 tiou.s-c_ 'FA City R11411ke 7 Zip /45.5 3 Lic# 0.494,71= h o ne# 715.- 3/ 3 -6100 <br />Consultant/ Sub Cntr Atha tta 006tifO kliSettkiti Address g 37 Slow; Pc( City 5/e11441 Lic# ''&Z17 Phone# 44,7-ine4, <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />x_NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") 0 DESTRUCTION (choose type below) <br /> <br />SOIL BORING # i — ecx.i..„. a OVER-BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 "Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />U MONITORING <br />El HOLLOW STEM DIA. OF BOREHOLE 7 4 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -1-v-i-o-4 TREMIE TYPE TO BE USED: WAUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE **PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Rq-4-letcktk <br />D OTHER:0 OTHER APPROX. BORING DEPTH Z-Ot 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 AGR EMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIR FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work I be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California tate Laws. <br />Signed x kV),AQ Title/Company Advatce4 Cr era v ro time-4414 <br />Date CS <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 'Art, 2 cc, Z2c <br /> <br />Print Name Y ewe_ L sLc <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ss -Lik,/vAlsc,1 <br /> <br />Date Issued <br /> <br />cin Area &Z <br />Date <br /> <br />Date I (1.6f 0 6 Final Inspection By tA <br /> <br />Date <br /> <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# F <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 5- C' I <br />.3 SI' 3, <br />-II S'''/ , re' <br />/I 27- 9 7/- I'd IpciqC sR#