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oPa'�l" SAN JOAQUIN COUNTY FILE COPY z --. ENVIRONMENTAL HEALTH DEPARTMENT �: . .,..,.. •a LOP II .. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION o- Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.siciov.orq/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 942 S. Stockton Ave Cross Street City Ripon Zip 95366 APN 259-34-012 Property Diamond Pet Food Processors Owner of Ripon. LLC Address 942 S. Stockton Ave. City Ripon Zip--L'3 6 6 phone (209)824-4640 C-57 Contractor Lawrence & Assoc. Address 3590 Iron Court City Shasta Lake Lic 539447 Phone (530)275-4800 Consultant/SubCntTrawrence & AssocAddress 3590 Iron Court City Shasta Lake Lic 539447 Phone (530)275-4800 Billable Party Lawrence & Assoc. Address 3590 Iron Court City Shasta Lake Zip 96019 Phone (530)275-4800 GIS Coordinates:X 37.734044 Y -121.11S723 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: OB-3, -6, -10, -12, DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 14 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: -13, -14, -15, -16, -18,-20,TH-2,TH-4,TH-5,TH-6 [0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Cement Bentonite Slurry ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ®PIPE ® MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,�tfc�all applic �I�r�i' a s. Signed /t�X/-r �' Title/Company Vice President, Lawrence & Associates Print Name David L. Kirk Date 10/24/2013 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS G�{Z S, STA4KT- VE R r('a✓ WORK PLAN DATED R I r- 2 1 2.0 APPLICATION ACCEPTED BY Kl,, DATE ISSUED /1- AREA /lo T 9 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE �} REQUEST PR# 11 1 $ 125x C7 Z 3�2 I Z C.t�U" F& ! �'7-/3 SR# (08gCf 5 2qo � 3 ?T RO# (3500) R# (2900) C-57 t WC _ -V/—WAIVER N/k C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC—A/)—