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10 '= �o U1 ,o an Joaquin 1.County. <br />r , - Environmental Health Department ` �� l <br />Uv 600 East Main Street; Stockton, CA 95202-3029 <br />JANs{ "MtTLO A�TION <br />(209) 468-3449 Fax. (209) 468-3433 Web: www.sjlgov.org/ehd ;• �i <br />trgoc: �'; N <br />well Permit F Application��J�RIJi1I11t1�N� N PERT <br />11 <br />NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED " O L GO <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 vuith San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. s. City,. of 'Tracy <br />95 WEST 11tH STREET TRACY 95376 �,..�Assessors <br />WELL Location Cross Street- ADAMSx City Zip +Parcel# Row <br />PROPERTY , ' "1 Ca # ^ E to 001+j <br />OwnerCity of Tracy -City HallAddress 333 CIVIC CENTER PLAZA --CityTracy ' Zip 95376 Phone# 209-831-6400 <br />ALL WELL ABANDONMENT - SLAGLE 3809 P easant Va ey Rd Placerville 95667. <br />#848359 T 800 948-1355 <br />C-57 Contractor Address City Zip Lic# PhOne# <br />Consultant 3'7 Shaw Rd. Stockton 71006 <br />1 Sub Cntr A.G.E, 8 q Address/" City .ic#. Phone#'209-46 <br />GIS Coordinates: Xi_ • *, Y '~ Z ZtP ; Township_. Range Section w. <br />WORK TO BE PER ORMED: • � . ,; � '� <br />0 NEW WELL 1 BORING (CZ, GEOPROBE, HYDROPUNCH, p -,AUGER, ODER-) 4 <br />0 SOIL BORING # ff <br />:O WELL # J <br />0 *Other <br />-- <br />I DESTRUCTION (choose'tgy below) <br />$ OVER -BORE. alAMETER8 .25 inch <br />'� PRESSURE GROUT Portland,,(Type <br />GROUT"SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS` T ' <br />8.25. inch <br />ONITORING HOLLOW STEM DIA. OF BOREHOLE 8 25 . MULTIPLE CASINGS two inch <br />Q MULTI-LEVEL WELL CASING DIA: __ "` <br />.0 EXTRACTION 0 AIR HAMMER/DRIVEN ' CASING THICKNESS'1 /4 TYPE OF CASING: 0 STEEL ° PVC, <br />OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SFAL BACKFILL. TREMIE TYPE TO BE U'SED:. )a AUGERS 'fl HOSE <br />0 AIR SPARGEI OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED:Yes 0 No (NOTE., MAXIMUM FREE -FALL DEPTH IS 30') <br />0SOIL BORING 0HAND AUGER GROUT SPECIF.ICATIONNnrtland (Type II) <br />:i <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH .201 and 351 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />it CCTOR C ROPOSED isE specifications in comment section) <br />COMMENTS: Monitoring wells: 6M ]6!Mnw <br />(201), MW -10(201), W-1 (35'), MW -11.(20!) <br />.-NOTE: OOFSITE 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 <br />�and <br />Regulations, and all applicable California State Laws. <br />1 Ltt�ltf�r' Project Manager/A.G.E. ' <br />Signed x — <br />Title/Company-Print Name Date William'Little * 26 January 207._0 <br />DEPARTMENT USE ONLY, <br />= <br />�S.ZI!o i <br />SITE MAP IN UNIT IV FILE, ADDRESS: 1 5 <br />WORK PLAN DATED: U441 <br />Application Accepted By Date Issued -:4 .�4 " Area <br />6 <br />ly <br />Grout Inspection By i ateI Finail In pection 89y— y µ ate �i <br />Destruction Inspection By Date' <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />1, <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />RECD BY DAT PERMIT! SERVICE REQUEST # <br />INVOICE <br />W <br />S # 5�I. <br />C-57 - t/ WC1,4 -WAIVER <br />EHD 29-02-001 WEB <br />9/11/2007 r <br />C-57 Letter of Authorization to sign permit Encroachment doc <br />FILE C OF <br />