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"•'"'-• SAN JOAQUIN COUNTY <br /> '` ORIG ► ^JAL <br /> r lI ? ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> r Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �%FU'itN <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 the San Joaquin County Environmental Health Department. <br /> Site Location 10540;� D/AM ONO Cross Street C-HrA2•f`WR WAY City 51000 -TDAI Zip 9sz05' APN ISS -3Z- 01 ? <br /> Property ,./ <br /> Owner �iAMOND FOODS AddresslOSO ,J D/AMOAID City 2TFJCIICr6AI Zip 9SZ05' Phone IM-4(ol-tooE70 <br /> C-57 Contractor Address ddress City Lie Phone <br /> Consultant'Sub CnMejAt T98dtr ll ress 111.7 LOIJ& 'RALM AVE- City /-t0DSST0 LiC755-156Y Phone 24q-574Y--Z I <br /> Billable Party A-TC.AQTOCIA'rF6 Address 1117 WAI6 I�ALM AVb- City MO VP—S-170 Zip );3SI Phone 20-579-2Ltl <br /> CIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> WELL IDs �RC—PAI2 REP<AC!EHEn/T WEL4— '7�OKES 0 MW Sy M� MW 9 <br /> OTHER IDs <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC ❑ OTHER ` <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE C <br /> _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0INJECTION(Le AirSoarae.Ozone10HAND AUGER GROUT SPECIFICATIONS rV!' <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 4. <br /> _#OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE O <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE Z <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 1:7 <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS to <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and i <br /> Regulations,and all appli le California Laws. <br /> Signed _�. Title/Company ��JECT MAAIA6E72/aTC j�SSOL'tATES <br /> Print Name �AAJaI� +FOATSBY Date (a-'I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 1050 14M9AJb STe&-_r 'o <br /> WORK PLAN DATED f p <br /> APPLICATION ACCEPTED BY el-`Io RK1(ta1 DATE <br /> GROUT INSPECTION BY FINAL INSPECTION ATE7 3 Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO -AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> ;LCI 1� $125X I l25 1220 ere SI (5-083 <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 \Jh WC WAIVER, IVVI C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br />