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,an Joaquin County <br /> _� oy Environmental Health Department ITE <br /> 600 East Main Street, Stockton, CA 95202-3029 APO 1 4 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o L J UNIT IV <br /> P � c��u��t�v r <br /> ` FORS` Well Permit A lication C n f IS ` IC-E Zw <br /> "' <br /> NON-REFUNDABLE PERMIT EXPIRES IIYEAR FROM DATE ISSUED ERMIT�ERUCC�S <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 /> 8600 West Mokelumne Aveune Thornton 95686 Assessors 001-160-02 <br /> WELL Location Cross Street Thronton City Zip Parcel# <br /> PROPERTY <br /> PO Box 1810 Owner San Joaquin County Address 1810 E. Hazelton Ave City Stockton 95201 Zip Phone# 209-468-3000 <br /> ALL WELL ABANDONMENT - SLAGLE 3809 Pleasant Va ey 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*) b DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> G WELL# Monitoring Well MW-6 a PRESSURE GROUT <br /> 0*Other GROUT SPEC IFICATIONSportland cement <br /> COMMENTS: See Work Plan for Monitoring Well Destructions, 27 January 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING 30 HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:2 <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1/4 11 TYPE OF CASING: 0 STEEL :8 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 30' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ff 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' 0 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, Rul s and Regulations, and all applicable California State Laws. <br /> I.�'�/ �, Project Manager/A.G.E. <br /> Signed x W�,(,&'V ) Title/Company <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A-40FO <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued �//�9/r/f) Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection ByC&tlb-e Date 5/ f o <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> iv SR# 6oL2���. <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 />