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Pa�ln. SAN JOAQUIN COUNTY <br /> z - y <br /> ENVIRONMENTAL HEALTH DEPART NT F 1116 E L <br /> N P9 <br /> �m < SITE MITIGATION <br /> :•. - 1868 Hazelton Avenue, Stockton,.CA 95205-6232 UNIT IV <br /> c•.• .<- ;•� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orgleh <br /> ��FO•M1 <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 950 E Roth Road Cross Street McKinley AVP City/State French CampzIp95231 APN 196-030-01 <br /> Property French Cam 95231 209-983-4900 <br /> Owner Diamond Pet Food Address 250 E.Roth Road City/State pzip Phone <br /> C-57 Contractor URS Corp Address 2870 Gateway Oaks Drive City/State Sacramento Lic 769167 Phone 916-679-2000 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party URS Corp Address 2870 Gateway Oaks Drive City/State Sacramento Zip 95833 Phone 916-679-2000 <br /> GIS Coordinates:x,213 . 7 Y 6337774.61 <br /> —/Z f <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> -SOtL-BORtNG­1Ds <br /> -I <br /> ®WELL IDs EWNB6 This is an Pristina vvPll - <br /> ❑ OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONS?RUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 12" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _LIN EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: 0 STEEL M PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL 55' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION fl a Ar Soame Ozonel❑HAND AUGER GROUT SPECIFICATIONS existind 20 sack cement/60 Ib bentonite <br /> ❑OTHER: EI OTHER:Rescreen APPROX.BORING DEPTH 78' ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING[N No❑Yes:Casing Dia: Casing Depth:_ Bodng Dia: <br /> COMMENTS: Rescreening existing 6" diameter well with new 4"prepacked screen <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby ce,p"y at av prepared thiscation and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulation anddJ'' appli able Cal' r a law . <br /> Signed Title/Company URS Corp <br /> print Name Andrew Archuleta Date 2/5/14 <br /> S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESSU'' 5-6 k6T/-f <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY S.C*/kuvn DAT AREA /4- <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE 7RO# <br /> RO# INVOICE <br /> P} PR# <br /> o2q/3 <br /> $125, 1 0'S CO3 C!-EeaROIU -(0-1` 460 <br /> C-57 WC WAIVERO 1/VI- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC _ <br />