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"4 AN JUAQUIN cou NTY Greotness 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 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 Alley way behind 311 W. Main St. City/State/zip Ripon, CA 95366 Phone 916-464-4707 Water �Al it All �11&44i (AZ Board - Geoff Rada Cross Street Alley way behind 311 W. Main St., cross st. is Locust • • - • ' ��i�i��l�\�LOI►71NEali•7�Q�i•]�IltiA•�i��•iii Address - =A - • Contractor Cascade Drilling Address 3000 Duluth St. 3/l City/State/Zip Ripon, CA 95366 z'l2Z License# 1058836 Phone 916-638-1169 City/State/Zip West Sacramento, CA 95605 Consultant/Sub-ContractorAPTIM Environmental and Infrastructure, LLGicense# General 998883, Haz C-211048756 Address 4005 Port Chicago Hwy., Ste. 200 City/State/Zip Phone 925-288-9898 Concord. CA 94562 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 ~22 t0 28 ft bgS ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 2 -inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER NA (—XI SOIL BORING 3 M PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes E$ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, ozone) ❑ HAND AUGER GROUT SEAL DEPTH 0 to 28 ft bgS TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE L] PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs GW -1, GW -2, and GW -3 GROUT SPECIFICATIONS 5% bentonite / grout mix - temporary boreholes to be abandoned after Direct push drilling (DPT) soil and groundwater sample collection. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED 3 ❑OVER-BOREBentoniAMETER of inches to depth of feet WELL IDs GW -1, GW -2, GW -3 °r"-�E GROUT To depth ofO feet below surface GROUT SPECIFICATIONS Total depth to surface (5% bentonite/grout mid] EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE n PIPE 171 MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet APTIM is contracted by the CA State Water Board (DGS Service Agreement No 6308) to conduct the soil, groundwater, and soil gas sampling behind the former dry cleaning facility at 311 W. Main St., Ripon. Soil and groundwater sampling will utilize direct push drilling and will install temporary 2 -inch dia. borings, to approximately 22-28 ft bgs. Following sampling each location will be abandoned. Signed_ Print Name 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. Ja��r�s Teo Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Title/Company Project Manager-/ APTIM Date 03/16/2022 Date Issued: DEPARTMENT USE ONLY FA Name C r nwq-� ;'s,n At d q-0 6 09 4 R'� S� 00950 Z.d 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 p µ/A pC� FA Address � p� � FA# n 0 z FA PE G� 6 (� WP Reviewed By J 4/t% Work Plan Date �p V,�� 2 OZ.I ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑,/MFR COMMENTS/CONDITIONS: Pe L vel -ell � > s � C (� "Xtc /JS t 3• . a Iref� .Lb �w V� WP TYPE PE SC FEE INFO AM/T�R.EMITTED CHECK# RECV'D BY DATE WELL PERMIpT►# INVOICE# Permit 20105 313 $152x 3 "T S cc / 3l�Tl2 oJFo� ®O wvvw.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application