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't"'H an Joaquin County <br /> s Environmental Health Departme n SITE <br /> to 600 East Main Street, Stockton, CA 95202-30 �� `� <br /> ,� i F� 11 TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> I1ORa Well Permit Application 4 <br /> HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 444a�PfQgade in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> San Joaquin County Right of Way Thornton 95686 Assessors D11 L <br /> WELL Location Cross Street Thronton City Zip Parcel# T_Of <br /> PROPERTY <br /> PO Box 1810 I�r��S�ls <br /> Stockton 95201 209-468-3000 'I <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 TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) I DESTRUCTION (choose type below) <br /> ®SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# Monitoring Well MW-2 Il 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 /> $MONITORING 3I HOLLOW STEM DIA.OF BOREHOLE 8" a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 211 <br /> __ <br /> Q EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 1/411 TYPE OF CASING: a STEEL In PVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 30' TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 8 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Portland (Type II) <br /> a OTHER:_D OTHER APPROX.BORING DEPTH 30' IFBOLTED 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, Rule and Regulations, and all applicable California State Laws. <br /> Signed x 0 Title/Company Project Manager/A.G.E. <br /> Print Name William Little Date 22 December 2009 <br /> DEPARTMENT USE ONLY p <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J_LCah A), <br /> WORK PLAN DATED: U [//J� <br /> Application Accepted By Date Issued �� Area (T <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date p <br /> v <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 /> baa 66_ 30F37 SR#,)051197 7 <br /> C-57_ W_-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />