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C-57 Letter of Authorization to sign permit Encroachment <br />L.1S4-‘2, <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 /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 />Assessors ,. <br />WELL Location (DOL tJ W;1-1,1 Cross Street C- 511 • City E.1-1)ek.--/-0e1/4- Zip 6/52-6Z- Parcel# /31' <br />PROPERTY . <br />Owner CAN) (-A-Atkuor-CiAi. Address (D07 1.1- CA 4tWk.111.... 4. City Zip qciC -2—Phone# IWO git irl In_ <br />Pi-Int <br />C-57 Contractor ettStack bt;(1 ill Address V32 bitnfe C• f e c I e-- cityc, do i A zipqs 74 2Lic# 1 115710hone# ell 6 - G3 r-a6 1 <br />Consultant / Sub Cntr AchltlAtt& eltICILVIWAIMMAddress 9J37 Awn) V-di City chtk--44)14 Lic# 6 wz 17 Phone# (7t1) 4107 <br />GIS Coordinates: X Township <br /> <br />Range Section <br /> <br />WORK TO BE PERFORMED: <br />xNEW WELL I BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />VWELL # <br />13 *Other <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />)MONITORING ;11,HOLLOW STEM DIA. OF BOREHOLE V ['MULTIPLE CASINGS ['MULTI-LEVEL WELL CASING DIA: 2 1L_ <br />Ei EXTRACTION fl AIR HAMMER/DRIVEN CASING THICKNESS Oil, go TYPE OF CASING: 0 STEEL 11C'VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL I Lib' + TO:\ TREMIE TYPE TO BE USED: WAUGERS ['HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: titYes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />['SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Vor-i-keeA4 <br />0 OTHER:0 OTHER APPROX. BORING DEPTH igoici- 2:t6- RPOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Ak:A C OVWAil-ClaOW( )C,Lf 60-CtelA ir / 2_ <br />NOTE: OFFSITE 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 <br /> <br /> Title/Company SIX Cie otiist vatmett Cietatkweccieti, Tor. <br /> <br />Date t 2- - <br /> <br />-Cu, c.e. odic1. F-is\rvi'c <br /> <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (o o <br />WORK PLAN DATED: -3-ttnAA.cA".A 24c 2-c2os— <br />o DESTRUCTION (choose type below) <br />13 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />- <br />i Date Issued C/Nru,,,Nee, Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: 'TWO J-( I'$ gTi <br />Date Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# F <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PERMIT / SERVICE REQUEST # INVOICE <br />3 a-0 I <br />3 5-0 3 <br />it tr9 ‘c,c' <br />g 61.+1•00 2- 3o 2. i Gif 1/1/04. SR# L--I s'Llz..c? <br />C-57' WC -WAIVER <br />EHD 29-02-001 <br />6/22/04