Laserfiche WebLink
or an Joaquin County <br />Environmental Health DeparteLL C M <br />n ` 600 East Main Street, Stockton, CA 95202-3029 MM <br />TW <br />` (209) 468-3449 Fax: (_209) 468-3433 Web: www,sjgov.org/ehd JAWION <br />4<lzotz�`4 ENVIROWW" ATH <br />Well Permit Application PE <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6N_ <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 />WELL Location 95 WEST 11tH .STREET Cross Street `AnAMS TRACY 95376 Assessors 2.33-130-27 <br />City ZIP Parcel# <br />PROPERTY <br />Owner Joseph Panetta95 West 11th Street Tracy 1 95376 925-743-9023 <br />Address City Zip . Phone# <br />ALL WELL ABANDONMENT - SLAGLE .3809 P easant Va ey R Placerville' 95667 <br />C-57 Contractor I Address #848359 1 800 948-1355 <br />City Zip Lic# Phone# <br />Consultant 1. Sub Cntr G. 2. Address 537 Shaw,Rd. City StocktonLic# Phone#209-467-1006 <br />I. -7A III <br />_-I , V <br />GIS Coordinates: X �� Y24,Township � .4 � `� Range Section <br />WORK TO BE PERFORMED: <br />O NEW WELL 1 BORING (CPT• GEOPROBE, HYDRO' --4CH, HAND -AUGER, OTHER•) b DESTRUCTION (choose type below) <br />0 SOIL BORING # q 'J�'' In OVER -BORE. DIAMETER a • 5 inch <br />0 WELL #. q / 12- �/ 13 PRESSURE; GROUT <br />0.Other .: GROUT SPECIFICATIONS Portland (Type I I ) <br />COMMENTS: Monitoring Well Destruction Work Plan, 25 January 2010 Per Si Co Code <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />8.25 .inch <br />:0 MONITORING i l HOLLOW STEM DIA. OF BOREHOLE 8.25 0 MULTIPLE CASINGS0 <br />MULTI-LEVEL WELL CASING DIA two inch <br />0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 1/4 c TYPE OF CASING: 0 STEEL 13 PVC 0 OTHER: j� <br />0 VAPOR B MUD ROTARY DEPTH OF GROUT SEAL 23' -and 35' TREMIE TYPE TO BE'USED:'!:70 AUGERS" 0 HOSE CC <br />0 AIR SPARGE] OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: N Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GRiOUT SPECIFICATIONS Portland (Type II)- <br />a <br />I)- <br />a OTHER: 0 OTHER APPROX. BORING DEPTH 20' and 35' BOLTED TRAFFIC BOX or U STOVE PIPET <br />' CONDUCTOR CASING PROPOSED -' I ' (if YES, list specifications in comment section) <br />COMMENTS: Monitoring wells: MW -5(151), MW -9(201), MW -7(201), MW-13(35'),.MW-12(20'.) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESSAGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />' s _ <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 />��1 !:% Y if Project Manager/A'"G?:E. <br />Signed x W Title/Company n <br />Print Name William Little at , r Date 26 January 2010 <br />,x DEPARTMENT US& ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ... <br />WORK PLAN DATED: <br />Application Accepted, B on Date Issued .. , Area <br />Grout Inspection By II to i Fi I 1 spection By � � �=Oate <br />Destruction Inspection By Date i ! l ! a <br />:f <br />COMMENTS 1 CONDITIONS: <br />ACCOUNTING ONLY: AID# ? <br />FAC# r r. <br />PE CODES FEE -INFO AMOUNT REMITTED CHECK # <br />REC'D BY <br />DATE <br />PERMIT 1 SERVICE REQUEST # INVOICE <br />F <br />C-57 -V WC -WAIVER_ C-57 Letter of Authorization to sign - errrtit_jLEn <br />EHD 29-02-001 WEB 4. v <br />9/11/2007 <br />FILEUPY <br />