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o Ul �an Joaquin County <br /> Environmental Health DepartmeiRS-' i N <br /> O600 East Main Street, Stockton, CA 95202-3029 �� :,, rnSFE <br /> IGATI <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/A", 1 4 'Lbia UNIT IV <br /> ��P <br /> `IFOR Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISi"MIT/SERVICE <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 /> Thornton 95686 Assessors <br /> WELL Location 26090 N. Thronton Road Cross Street Stockton City Zip Parcel# 400 1 1 SO49 <br /> PROPERTY1}K y 4t' <br /> Ron Barber 11041 Small Road Manteca 95336 209-932-0606 <br /> Owner Address City Zip Phone# <br /> ALL WELL ABANDONMENT - SLAGLE 3809 Pleasant Va ey R 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 Stockton Lic# 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# )pcOVER-BORE. DIAMETER <br /> 0 WELL# On-si a weiis and reme cation wells VW-1,Vw-2,Vw-3,Aw-1 8 PRESSURE GROUT <br /> 0*Other MW-3,MW-a,Mw-s, MW-1 GROUT SPECIFICATIONSportland cement <br /> COMMENTS: See Work Plan for Monitoring Well Destructions, 27 January 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING )1 HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 21, <br /> _ <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 30' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 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 301 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 /> Signed �lQ,/Z, � Title/Company Project Manager/A.G.E. <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 24,�265U <br /> WORK PLAN DATED: p <br /> Application Accepted By_ �M,Tc/t Date Issued rf U Area qq� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date I N1 10 <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 /> �0Ct_ D �O$3 C- y 1 !D SR#OOSS -77q <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 />