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-.tn Joaquin County <br /> oZa Environmental Health Depart m SITE <br /> 600 East Main Street, Stockton, CA 95202-3 E �8v[�-#TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh <br /> �q •.......�,;P APR UNIT IV <br /> `eFOR Well Permit Application 1 4 Lind <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT[ A40NMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des ri71h1�� ade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Depant. <br /> San Joaquin county Well Site #2 W/IN CSA #12 Thornton 95686 Assessors <br /> WELL Location Cross Street Thronton City Zip Parcel# <br /> PROPERTY PO Box 1810 <br /> San Joaquin Count 1810 E. Hazelton AveCity Zip Phone#Stockton 95201 209-468-3000 <br /> Owner 4 Y Address 11 <br /> ALL WELL ABANDONMENT - SLAGLE 3809 P easant vailey Rd Placerville 95667 #848359 1 800 948-1355 <br /> C-57 Contractor Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr A.G.E. Address 837 Shaw Rd. City StocktonLic# Phone# 209-467-1006 <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 6 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# Monitoring Well MW-7 11 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONSp°rtland cement <br /> COMMENTS: See Work Plan for Monitoring Well Destructions, 27 January 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING i1 HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 211 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1/411 TYPE OF CASING: 0 STEEL :8 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3 0' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: if Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Portland (Type II) <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 30' O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NO (if YES,list specifications in comment section) <br /> COMMENTS: See CRWQCB-approval letter, dated 28 January 2010 <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 <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Project Manager/A.G.E. <br /> Signed x �J�J��[['TTTT Title/Company <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: k5,0 0 A.I. `r&.- .. RJ <br /> WORK PLAN DATED: <br /> Application Accepted By U Date Issued //r ( Area 997 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a.9.oZ bO bo_ 30 F b �0 sR# o a f <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />