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�o. U'^► �o ,an Joaquin County <br /> Environmental Health Depart m SITE <br /> 600 East Main Street, Stockton, CA 95202-3IE(C <br /> 209 468-3449 Fax: 209 468-3433 Web: www.s' ov.or ehd E�� #ITIGATION� � � > >g � UNIT IV <br /> Well Permit Application APR Y <br /> 4 �UjU <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT SNONNIEN T HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des ri � ade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health DepartPfiLnt. <br /> San Joaquin county Well Site #2 W/IN CSA 412 Thornton 95686 Assessors -.10 �/t n <br /> WELL Location Cross Street Thronton City Zip Parcel# ,q <br /> 43 <br /> PROPERTY <br /> PO Box 1810 "f <br /> mi <br /> 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 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 T0-BE PERFORMED: <br /> p NEW WELL I BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) b DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> D WELL# Monitoring Well MW-7 8 PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONSportland cement <br /> COMMENTS: See Work Plan for Monitoring Well Destructions, 27 January 2010 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 13 MONITORING211 <br /> �G HOLLOW STEM DIA.OF BOREHOLE 8" Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 174-11 TYPE OF CASING: 0 STEEL �PVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 3 01 TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> Q AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ff Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland (Type II) <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 30' 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 /> )),,^^, �P Project Manager/A.G.E. <br /> Signed x W( UOL_' Title/Company <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: oa4000 N <br /> WORK PLAN DATED: //�� � � pp a UI U G <br /> Application Accepted By /�}'r�n�' �. Date Issued � / U Area 9 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By 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 /> 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 />