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tv <br /> FILE COPY <br /> SAN JOAQUIN COUNTY 40 <br /> �.•a..,, ..o� <br /> x� ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> . � P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <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 /> Street right-of- <br /> Site Location Parallel Avenue Cross Street Reynolds Avenue City Ripon Zip 95366 APN way <br /> Property Diamond Pet Food Processors <br /> Owner of Ripon LLC Address 942 S. Stockton Ave. City Ripon Zip 95366 phone (209)824-4640 <br /> C-57 Contractor Lawrence & Assoc. Address 3590 Iron Court Cit Shasta Lake 539447 <br /> L Y Lic Phone (530)275-4800 <br /> Consultant/SubCntlr'awrence & Assoc Address 3590 Iron Court Shasta Lake 539447 <br /> City Lic Phone (530)275-4800 <br /> Billable Party Lawrence & Assoc. Address 3590 Iron Court City Shasta Lake Zip 96019 phone (530)275-4800 <br /> GIS Coordinates:X 37.734767 y -121.114819 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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) <br /> 1 #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: -27 ®PRESSURE GROUT TO DEPTH OF 44.5 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Cement Bentonite Slurry ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ® PIPE ® MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,a d II applica Cal'f� w <br /> Signed (i�� / - Title/Company Vice President, Lawrence & Associates <br /> Print Name David L. Kirk Date 10/24/2013 <br /> DEPARTMENT USE ONLY <br /> Q / <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS f I Z 5 S V?:e an) A&jesVq& <br /> WORK PLAN DATED iPkf L O/3 <br /> APPLICATION ACCEPTED BY Nnl�lf�� ( DATE ISt, u EA (Gii49 <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE /frf.-`t13 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> p U REQUEST PR# <br /> ccl U 2 $125 x �xj 12s5 �vtcK�r Irk-Z&l SR# C) <br /> 2l0 RO# <br /> 3500) <br /> PR# <br /> (2600) <br /> C-57 t/ WC _WAIVER yvf C57 LETTER OF AUTHORIZATION TO SIGN PERMIT J/ ENCROACHMENT DOC l- <br />