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U'N _an Joaquin County <br /> = s Environmental Health DepartmekE�, VE; SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 IGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/A" 1 4 ZUiU UNIT IV <br /> R��FORN`P Well Permit Application ENVIRONMENT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISMrT/SERV/CEESLTH <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 /> 6090 N. Thronton Road Thornton 95686 Assessors <br /> 2c� <br /> WELL Location Cross Street Stockton City Zip Parcel# 00 1 <br /> PROPERTY 1}K 09(lb <br /> Ron Barber 11041 Small Road Manteca 95336 209-932-0606 <br /> Owner Address City Zip Phone# <br /> ALL WELL ABANDONMENT - SLAGLE 3809 Pleasant Valley Rd placerville 95667 <br /> #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 /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) b DESTRUCTION (choose type below) <br /> a SOIL BORING#, 4YOVER-BORE. DIAMETER <br /> WELL# On-site we s an remediation wells VW-1,VW-2,VW-3,AW-i <br /> � Ofl PRESSURE GROUT <br /> G*Other MW-3,Mw-4,MW-5, MW-1 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 -�n HOLLOW STEM DIA.OF BOREHOLE 8" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:_2 <br /> a EXTRACTION B AIR HAMMER/DRIVEN CASING THICKNESS 1/4 11 TYPE OF CASING: a STEEL :8 PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 30' TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland (Type II) <br /> a OTHER:_D OTHER APPROX.BORING DEPTH 30' lyBOLTED 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 /> IAXJLiA� Project Manager/A.G.E. <br /> Signed x Title/Company <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �-. 650 7?,'� A-,..( <br /> WORK PLAN DATED: p <br /> Application Accepted By il Date Issued U Area <br /> Grout Inspection By D p Date Final Inspection By Date <br /> Destruction Inspection By (C�.�TC—� Date (] <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 /> d-90a-- 0- 60 30$3 y OL _9J/7//01/o SR#0051 -7)q <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 />