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SAN JOAOUIN ��Nry Grea�rless grt�ws 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 �� "{'p-�/'Qk'� CALL (209) 953-7697 For INSPECTIONS � ��ah 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 Intersection Stockton Ave and 1st Street // 142 S. Stockton Avenue Cross Street See attached map Property Owner* City of Ripon Address 259 North VUlma Avenue C-57 Contractor Geocentric Drilling, Inc Address 1980 South River Road, Ste E COnSUltant/SUb-Contractor Haley&Aldrich, Inc Address 426 17th Street, Suite 700 City/State/Zip Ripon/CA/95366 AP N NA // 25939025 City/State/Zip Ripon/CA/95366 License# 1073146 Phone Phone 209-599-2108 Phone 916-304-2665 City/State/Zip West Sacramento/CA/95691 License# Phone 510-879-4579 Clty/State/Zlp Oakland/CA/94612 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 16 feet ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2 5" ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR �►e�ls 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER ❑ SOIL BORING ® PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Airsparae, ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note: Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SV -131 and SV -132 GR01 �T cvGri�icn-nnnis N--`^�ment Grout � w � �^ � � T' �� DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: ccHEci<ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER -BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUpGERS ❑HOSE ❑/PIPE MUSHROOM CAP ❑ 3 feet below surface orL feet below surface if >3 feet COMMENTS: ��. ('lir � �/ � Z� ZZ , ''�' ✓�% � � -e—'S Gl��-- i. 6 � r��l� � �. I hereby certify that I am authol�i d to co plete this application and that he work will be done in accorda ce with QJ� San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed GG� Tltle/Company Technical Specialist, Haley &Aldrich, Inc �� Print Na Jenn er G Ivin Date 6/27/2022 (/v� S . Utl'AK I MtN I USt ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: =acilit /Site Infor ation FA Name ,( � U � FA Address � FA PE � A � WP Reviewed By ❑ C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Wairver ncroa COMMENTS/C N ITION� �GroGit,k � 6ri � �� = ��i°�c � �� u�a� �'�1� � ��ivc�r 's WP TYPE PE SC FEE INFO AMT REMI CV' Permit � � u 3 � $15 x � �'j i.�,c� r�,�('G t. 2 h 1868 E. Hazelton A�ienue oc EHD 29-01 04-04-07 �:� �: Date Issued: Permit �bZ 1 PR# � 5 T"T �- Work Plan Date 6 � ZD`' Access Agreement ead Agency Approval MFR L...TE � WELL PERMIT# �/� tzz � Pop's `� ,'' - -. �. INVOICEtF 1 i n ,ali .0 T 209 468-3420 � F 209 464-0138 � www.sjcehd.coh� , O�Q � �} � � Site Mitigation Well Permit Applicatior - — - -