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'� • L E C U^ P Y <br /> PqU I ly <br /> SAN JOAQUIN COUNTY <br /> 4.. �``-` '� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> V. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNIT IV <br /> ��FOR <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 942 S. Stockton Ave Cross Street City Ripon Zip 95366 APN 259-34-009 <br /> Property Diamond Pet Food Processors <br /> Owner. of Rion. LLC Address 942 S. Stockton Ave. City Ripon Zip 95366 Phone (209)824-4640 <br /> o <br /> C-57 Contractor Lawrence & Assoc. Address 3590 Iron Court City Shasta Lake Lic 539447 Phone (530)275-4800 <br /> Consultant/SubCntrawrence & Assoc Address 3590 Iron Court City Shasta Lake Lic 539447 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 37.734044 Y -121.115723 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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.Air Sparge,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: TH-3Cd-**00- ® PRESSURE GROUT To DEPTH OF 19 D FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ement4eiEtat;� Gam - ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ® PIPE R 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed Title/Company Vice President, Lawrence & Associates <br /> Print Name David L. Kirk Date 10/17/2013 <br /> C DEPARTMENT USE ONLY p <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS o L l Sc 5 .CIcro/u <br /> WORK PLAN DATED A Z o ( <br /> APPLICATION ACCEPTED BY . Y d K .cw <br /> ct DATE IS - � EA__ <br /> GROUT INSPECTION BY FINAL INSPECTION BY D�Ku✓r'1 ATE �/'/ZZ-•(3 <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 SERVICE I RO# INVOICE <br /> REQUEST PR## <br /> 29 07- $125x / 3q2i- SR# 36v(a <br /> Roo) <br /> PR# <br /> (2900) <br /> C-57-17- WC _WAIVER r q C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ` ENCROACHMENT DOC­4�� <br />