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SAN ]OAQUIN Environmental Health Department CCNU NTY 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 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 Unified School District Address 364 North Acacia Avenue C-57 Contractor Geocentric Drilling, Inc Address 1980 South River Road, Ste E City/State/Zip QP N 25904012 n/CA/95366 City/State/Zip Ripon/CA/95366 nse# 1073146 Consultant/Sub-Contractor Haley &Aldrich, Inc Lice Clty/State/Zip West Sacramento/CA/95691 License# Address 426 17th Street, Suite 700 Clty/State/Zip Oakland/CA/94612 Phone 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 161ft, 161ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ 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 ® PVC ❑ OTHER stainless steel screen, 57 -157 feet bgs ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ®No Boring Dia: Casing Dia: 6 -in Casing Depth: 57 ft ® INJECTION (Air sparge, Ozone) 2 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE la PIPE ❑ OTHER ® OTHER(!!q GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) 0 1 WELU SOIL BORING IDs I-1 and IW -2 GROUT SPECIFICATIONS Nc.eat Cement Grout, 0 - 50ft logs W &al I "X f10,� 1A )IN r-l:� DI0►ww DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED DESTRUCTION METHOD: (CHECK ALL THAT APPLY) WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS ❑HOSE [:1 PIPE COMMENTS: Signed Print N ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet I hereby certify 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. Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Title/Company Date � n FA Name 51200$5I q 1+1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 468-3420 � F 209 464-0138 1 �C, FA Address ZTQ i " l FA# Q d 2 PR# � �� FA PE �jQ WP Reviewed By � Work Plan Date ,e b Z 0 ❑ C. C-57 Authorization for Other to Sign Permit E] Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit E:1 Access Agreement Lead Agency Approval R COMM ENTS/OONDITIONS:11 /-C J ST�(i Vt I � oG�d s . ,9t .�� p tt(� G� s ;n Z �� s (� �p.� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Z 0l 1313 x 21303;7?qTW � ,� W as 4` 01 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application