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SANJOAQUIN Greatness grows here. Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS ti 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 San Joaquin County Well Standards, Job Address 301 North Acacia Avenue Cross Street Pine Street Property Owner* Ripon Unifed School District Address 364 North Acacia Avenue C-57 Contractor Geocentric Drilling, Inc Address 1980 South River Road, Ste E Consultant/Sub-Contractor Haley&Aldricn, Inc Address 426 17th Street, Suite 700 City/State/Zip Ripon/CA/95366 Phone AP N 25904012 City/State/Zip Ripon/CA/95366 License# 1073146 Clty/State/Zlp West Sacramento/CA/95691 License# Clty/State/Zip Oakland/CA/94612 209-599-2131 Phone 209-599-2131 Phone 916-304-2665 Phone 510-879-4579 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 184ft ❑BOLTED TRAFFIC BOX ®STOVE PIPE ® EXTRACTION (Vapo Water 1 ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 10 -in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Schedule 80 TYPE OF CASING: ❑ STEEL la PVC ❑ OTHER stainless steel screen, 160 -180 feet bgs ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: 10 -in Casing Dia: 6 -in Casing Depth: 160ft ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE ❑ OTHER ® OTHER Sonic GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) (, WELL/ SOIL BORING IDs RPS -3 GROUT SPECIFICATIONS Neat Cement Gjout 2,T `� s o cuyc;5i DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED r7 AUGERS 1-1 HOSE I—I PIPE COMMENTS: I hereby cert DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface 1-1 MUSHROOM CAP [ 3 feet below surface or feet below surface if >3 feet ify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed k N �� Title/Company (sG-1t C'Ac s Print Name 1V I - k � A Lu I uNJ Date � /(' < IJSE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: IJ lot Facility/Site Information r. Date Issued: FA Name �-p NJoi,V'� �h-a � i � �"�'�-rQ's-{'rq'►,Q--�->(�Q.t�'e � SJ`Z 00 $S 1 q 1868 E. Hazelton Avenue I Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjgov.org/ehd � � S �� FA Address 3(� M a'�J-�l FA# �� Z� 1 1 PR# (7 �� FA PE WP Reviewed By ��' Work Plan Date �� Za Z ❑ C-57 -57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval MFR COMMENTS/CONDITIONS, c res V a r iuh1L� C*f'rtVo �s 1lf'-F rQr c will Sand araC 4'• WO ��: l - �,l oes over- ewrs /� G14' M- it WT or t 6� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 31$1152 x 303 V " P 0 04 3t o EHD 29-01 06-28-21 Site Mitigation Well Permit Application