Laserfiche WebLink
C-57 Letter of Authorization to sign permi Encroachm <br />WELLARMIT APPLICATION F eM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />AMENT HEALTH 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PERMIT/SERVICES (209) 468-3449 <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 />..., <br />WELL Locatior6iguthit 23z/ witat 01/7--Cross StreetL /44//g City ..4D/1444 Zip 9-5-21)C Assessors <br />PROPERTY Owner <br />Parcel# <br />Cl 17 ,( Mdre re4e) Zip A02 phone#41),..?7-64 7 <br />4126 . • %ddress 3(032. 01+4,C- CLA- city keo ztpkv,C67Ouo#EKL9.hone#M6) C-57 Contractor, <br />Consultant / Sub Cntr 04-ad Address 827._...40e0 caySmt44)Lictt 6i3O7 Z7 Phone# (74167 00(0 <br />GIS Coordinates: X Y , Township Range Section <br /> <br />WORK T RFORMED: <br />)<1 <br />Eil(Q..73 <br />WELL / OR1NG ( CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) - 0 SOIL BORING # <br />za'W ELL # <br />*Other: Grout Specifications: <br />COMMENTS <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 13 1/ MULTIPLE CASINGS? U MULTI-LEVEL? 0 WELL CASING DIA: 2 II <br />CASING THICKNESS -5 (Lk 40 TY,. PE OF CASING: 0 STEEL XPVC fl OTHER: <br />DEPTH OF GROUT SEAL "I" ac TREMIE TYPE TO BE USED: /fl AUGERS 1:1 HOSE <br />GROUT SEAL PUMPED: 0 No (NOTE: MAXIMU FREEt-FiALI_ DEPTH IS 30') <br />GROUT SPECIFICATIONS' 911 b ko 6 95ti fir 0 <br />APPROX. BORING DEPTH c.j. f KIOLTED TRAFFIC BOX or El STOVE PIPE <br />CONDUCTOR CASING PROPOSED? NO ( if YES, list specifications here): <br />*COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Title/Company -N t- / A4.4-9 (9-L9—Z) <br />Print Name ek A i e_{ ik_c_. I vA1.90,, Q tt <br />DEPARTMENT USE ONLY <br />Date I 1 1 (--) 1 0 1- <br />SITE MAP IN UNIT IV FILE, ArREISS: S 2-- \ 8 • W Lfs.ot4 GOQ.A6- <br />WORK PLAN DATED: "A-• tc6 t) z <br />Application Accepted By <br />Grout Inspection By Date <br />Destruction Inspection By <br />COMMENTS / CONDMONS: <br /> <br /> Date Issued <br />Final Inspection By <br /> <br />Date <br /> <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REVD BY DATE ---------' INVOICE MIT / SERVICE REQU <br />3 -40,1 , A ct. co tctc6-4- LIS 112.410 40036-i z_o <br />, <br />JAN 2 0 2004 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />DESTRUCTION (choose type below) <br />U OVER-BORE <br />0 PRESSURE GROUT <br />TYPE OF WELL <br />*MONITORING <br />EXTRACTION <br />INSTALLATION TYPE <br />I HOLLOW STEM <br />fl AIR HAMMER/DRIVEN <br />I] VAPOR a MUD ROTARY <br />U AIR SPARGE / Ozone 0 PUSH POINT <br />SOIL BORING a HAND AUGER <br />OTHER: ri OTHER <br />C-57 J WC \/-WAIVER 8/29/02