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Area <br />C-57 Letter of Authorization to sign permiti. Encrophment doc <br />a44-1-4- <br />At 62 <br />5 <br />W#0 <br />JAAtitim <br />EIvviRofvu,,UN <br />p CtiT <br />ERwcEs F. tAtAJ Th <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 />5 --tee*vAi <br />Assessorsi z <br />WELL Location °111/''' 6:41"1"--17 <br />7,r <br />Cross Street /13/1/4 City Zip-- ‘.5-06.)Y Parcel# '4) <br />7y <br /> <br />PROPEUY <br />Address ,514 A cot-iv city 5-10c,e len/ zip nzrzPhone# 0°9 6 40 Owner -3 19 fl/0/ <br />C-57 Contractor Gr/i-e.bil Address 036, 5- 6e/4 165441 ,02- City ..-CV4110"° Zip 9C2425—Lic# C/e74hone# "Ong 4165— 87/-e- <br />Consultant / Sub Cntrif27H/d 6W41/1/6014k4-Address 44;44 AltglaA‘LiC# C 5-77417 Phone# .72 47 5711 <br />GIS Coordinates: X , Township Range Section <br />y*?r <br />RK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />OIL BORING # <br />WELL# --/(2 a Other <br />COMMENTS: <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 /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> <br />,RE r'21 /2, GINAL r-- <br />L. Wit' It <br />ION <br />I IV <br />o DESTRUCTION (choose type below) <br />a OVER-BORE. DIAMETER <br />O PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />1—) <br />D MULTI-LEVEL WELL CASING DIA: _ <br />T PE OF WELL <br />MONITORING HOLLOW STEM <br />IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e` " a MULTIPLE CASINGS <br />U EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS-56h' lid TYPE OF CASING: 0 STEEL PVC a OTHER: <br />a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL -7'3 ( TREMIE TYPE TO BE USED: ett AUGERS 0 HOSE <br />O AIR SPARGE/ OZONE a PUSH POINT (GP or CPT)GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br />0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 5--rd /0,04 6 ° /°"e 944-54(---/e ‘-‘-'-.,671/7. <br />a OTHER: a OTHER APPROX. BORING DEPTH 8.C./ )(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 />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 r/‘Z Title/Company 6-6(4 //1/ /4r7;4-/-A?e. <br />Print Name Name Date / 6r 7 /#/,1 AGA/ <br /> <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />COMMENTS / CONDITIONS: <br />DEPARTMENT USE ONLY <br />2.3-45- <br />-o 0 q- <br />Date Issued <br />te Final Inspection By <br />Dat <br />/v271v c _ b <br />Application Accepted B <br />Grout Inspection By <br />Destruction Inspection By <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE - v---- -- -z. ST # <br />3.50 ( — ,5o3 - - - - - <br />fs.41 <br />2C3-5 / 131. (II \ 2- 3 L\ 6 c-c- 1 `kN SR fi W970 <br />C-57 WC -WAIVER <br />EHD 29-02-001 <br />6/22/04