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%an Joaquin County FILE COP Y <br /> u Environmental Health Department SITE <br /> i� 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sigov.or 9CSM�U NIT IV <br /> b:P QN <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AN 4 Z010 <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. his application�isMIA <br /> inMI ycompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environ ttiulity1"SViC� essors 147-160-03 <br /> Stock Vhtcel# <br /> WELL Location 1201 South center street Cross Street Jackson City <br /> PROPERTY Address 1201 south center street <br /> Ci Stockton Zip 95206 phone# 209-915-9638 <br /> Owner Fernando Hatcher Jr. #848359 1 800 948-1355 <br /> ALL WELL ABANDONMENT - SLAGLE 3809 Peasant Va ey R Cetyl acervi--�Ip95667 Llc# phone# <br /> C-57 Contractor Address <br /> A.G.E. Address 837 Shaw Rd. City <br /> Stockton Lid! Phone#209-467-1006 <br /> Consultant/Sub Cntr <br /> 31. D ,y 121, Township Range Section <br /> GIS Coordinates:X <br /> WORK TO BE PERFORMED: DESTRUCTION (choose type below) <br /> ®NEW WELL 1 BORING (CSL GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) UU OVER-BORE. DIAMETER <br /> 0 SOIL BORING# a PRESSURE GROUT <br /> In WELL MW-10 GROUT SPECIFICATIONS <br /> p•Other — rw <br /> COMMENTS: See Monitoring Well Installation Work Plan, 04 November 2009 <br /> \ <br /> KE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS NITORING HOLLOW STEM DIA.OF BOREHOLE10" u MULTIPLE CASINGS Q MULTI-LEVEL WELLCASINGDIA: a _IR HAMMER/DRIVEN CASING THICKNESS 1/4 TYPEOFCASING: STEEL PVC QOTHER:RACTION D 63' TREMIE TYPE TO BE USED: g AUGERS a HOSE <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL <br /> Q Port allo nd(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Ix <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> g <br /> OTHER APPROX.BORING DEPTH 75' (BOLTED TRAFFIC BOX or STOVE PIPE OTHER: 0 f YES,list specifications in comment section) <br /> CONDUCTOR CASING PROPOSED No (i <br /> COMMENTS: See EHD-approval letter, dated 17 November 2009 n <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 j <br /> County Ordinances, Rules$nd Regulations, and all applicable California State Laws. 1 <br /> Project Manager/A.G.E. <br /> Signed 1/' Y1us�% n Title/Company <br /> Print Name William Little <br /> Date 22 December 2009 <br /> DEPARTMENT USE ONLYN 2) <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued / l�E —mea D <br /> Application Accepted By <br /> Grout Inspection ey Date /o /0 Final Inspection By _ <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COD FEE INFO AMOUNT REMITTED CHECK# RE 'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> oro 07 �3 l sR# ©gip/s� <br /> C-57 p�iyt/COK�WAIVEP, +57 Letter of Authorization to sign permit_ ncroachment doc_1/ <br /> EM 9/11/202-001 WEB <br /> 9/1112FILE COP <br /> 007 <br />