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• • <br /> rr WELL PERMIT /APPLICATION FORM siTE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> IVNAV 2 9 2��� ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> EN�IR" n11Ei�i <br /> HEACt" 304 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> PERMt 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 desenoed. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental <br /> Health Division. <br /> WELL Location 2245 W. CHARTER WAY Cross StreeTILLIE LEWIS STOCKTON ZIp92506 parcel# <br /> PROPERTY OwnerRAYMOND INVESTMENT COAddress P• 0• Box 567 Clty STOCKTON Zip 95201 phone# 466-8604 <br /> C57 ContractorPRECISION SAMPLINGAddress1400 S. 50th St. CityRICHMof1ryZip94804Li 36387phdne#510-237-4575 <br /> GEOMATRIX CONSULTANC.2444 MAIN ST. FRESNO #559-264STE. 215 <br /> —2535 <br /> Consultant 1 Sub Contractor City Lira Phone <br /> GISCoordlnates:X N 36'* 1(5' 47,3" W 119* 26' 3,7To>liNship Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> IdkEW WELL/BORING(CPT,GEOPROBE,HYpROPUNCH.HAND-AUGER,OTHER') U OVER-BORE <br /> a SOIL BORING# 0 PRESSURE GROUT <br /> p WELL# NEAT CEMENT GROUT <br /> •Other: Grout Specifications: <br /> COMMENTS: SOIL SAMPLING <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM CIA.OF BOREHOLE MULTIPLE CASINGS?DYES XK NO WELL CASING DIA:, <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5' TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> U AIR SPARGE xq PUSH POINT GROUT SEAL PUMPED: p Yes VNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> OZOIL BORING H HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER;_D OTHER APPROX.BORING DEPTH 5' 0 BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CAL*B. <br /> NSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> I hereby cerrepar d this application and that the work will be done in accordance with San Joaquin <br /> County Ordnd R gulations, and all applicable California State Laws. <br /> Signedx Title/Company SR. ENV. CONSULTANT/GEOMATRIX CONSULTANTS <br /> GLDSON Date11/28/01 <br /> Print Name - <br /> DEPARTMENT USE ONLY <br /> ���x% r✓9 1J ci 1 CIL Co �".11��`I CdrtS� , '` <br /> SITE MAP IN UNIT IV FILE, ADDRESS: `r /03/0 2 <br /> WORK PLAN DATED: ! tr ;Zc)c) <br /> � /�e nr <br /> c� - - �� UL'Ir I IF'JJ Area <br /> Application Accepted BY -Date Issued 2 r <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: '' K r Q' -`� f <br /> 3 cn s <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMODUNT REMITTED CHECK# REC'D BY DATE PERMIT)SERVICE REQUEST rA INVOICE <br /> l <br /> C-57_ WG=WAIVER C-57 Letter of Authorization to sign permit___-Encroachment doc_ 9/27/00 <br />