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C-57 Letter of Authorization to sign permit roachment doc <br />San Joaquin County <br /> <br />Envir. .nental Health Department SITE _ <br /> <br />600 East Main Street, Stockton, CA 95202-3029 — ' -MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/e1-4C I 2 5 2007 UNIT IV <br />Well Permit Application ri\IVIRONMENT tit:L.1h <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VICF:' <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 />L Assessors <br />WELL Location We, r--- ( 05 etIji-C, A" cP A Cross Street 5„ C., 11-44"-°4City /14.-4-ca. Zip 5-337 Parcel# <br />PROPERTX <br />Owner l ec <br />C-57 Contractor &raj1.. <br />Address 100/ 1,./e.$ Ie.54city ir ca.- Zip/ .5 31 Phone# 2474 ?-• 823---230 7 <br />Address 757) 4s( City pt4el","ceipft'S33 Lic#E$4Y01 Phone# 45.".30"3-90° <br />A As <br />Consultant / Sub Cntr4e.1,451.-ieo-c,.3 4""1-4 Address iritf ye,te..+:Je City 50nu...... Lic# <br />GIS Coordinates: X , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />ORIGINAL <br />Phone# -43 4 <br />pcSOIL BORING # C 3 / CFI <br />WELL # <br />0 *Other <br />COMMENTS: <br />p DESTRUCTION (choose type below) <br />0 OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />0 MONITORING <br />EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/ OZONE <br />qt.SOIL BORING <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 'I U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: __PA <br />CASING THICKNESS I TYPE OF CASING: 0 STEEL a PVC p.,-Ir6R• e DEPTH OF GROUT SEA LeU:fiedlp TREMIE TYPE TO BE USED: g <br />A <br />u HOSE <br />(KUSH POINT (GP or CPT)GROUT SEAL PUMPED: a Yes At'io/(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER APPROX. BORING DEPTH Go 4- <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />MUD ROTARY <br />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 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 acc ance with San Joaquin <br />County Ordinan les and qegu ati ns, and all applicable California State Laws. <br />Signed x Title/Company <br />Print Name ()Or( Id .eA Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 11 1,0 W YO.fernife. Av-tP ri uc <br />a WORK PLAN DATED: My 2t 2-007 <br />Application Accepted By V; Gf-p r ; . M Z r <br />Grout Inspection Byfiyett 2..,AL/l/e/hoidi--Lt-4A Date -7.3 -() <br />Destruction Inspection By Date <br />Date Issued 10&f4 31 2,0 0 7 Area J45-9 <br />Final Inspection /1 -16 <br />COMMENTS / CONDITIONS: A Zill./6 - 3 4,21 reT- 'in -1-17 4- f u rn Lan 0 -F W, Yeri <br />ACCOUNTING ONLY AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE INVOICE PERMILLSERvir:F Eg_(&JEST # <br />3E0 1 1 <br />89. O 0 1 8 9. o a o o 41, LOY/ S <br />C-57 WC -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007