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nED <br /> �o "'N..�o ..-n Joaquin County v�� <br /> z s� Environmental Health Department [JY S ITE <br /> 600 East Main Street, Stockton, CA 95202-3029 APP, ry ITIGATION <br /> rg(e <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.o4 c U <br /> �OIVN?EIVT y�t,r <br /> VICE UNIT IV <br /> �gGFFpR�`P Well Permit Application PERMIT/SER <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S <br /> Applicatior 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 001-160-02 <br /> WELL Location 8600 West Mokelumne Aveune Cross Street Thronton City Zip Parcel# <br /> PO Box 1810 <br /> PROPERTY Stockton 95201 209-468-3000 <br /> Owner San Joaquin County Address 1810 E. Hazelton Ave City Zip Phone# <br /> ALL WELL ABANDONMENT - SLAGLE 3809 Pleasant Valley Rd Placerville 95667 #848359 1 800 948-1355 <br /> C-57 Contractor Address City Zip Lie# 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-6 U PRESSURE GROUT portland cement <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: See Work Plan for Monitoring Well Destructions, 27 January 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING �G HOLLOW STEM DIA.OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_2'I__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 1/4 11 TYPE OF CASING: 0 STEEL ]a 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 /> SOIL BORING aHAND AUGER GROUT SPECIFICATIONS Portland (Type II) <br /> 0 OTHER 0 OTHER APPROX.BORING DEPTH 30' QfBOLTED 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 /> Signed x �"l KMWLI� 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: <br /> WORK PLAN DATED: '�-7 <br /> Application Accepted By Date Issued Y I y Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By �jy(,a—�� Date 7 /U <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> bo- iv SR# 604��`1.S <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 />