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SAN�JOAQUIN a Environmental Health Department COUNT Y c�crFoaa`% Gr, ., , ss r,i ws here. 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 N Acacia Ave (for 230 Industrial Ave.,Ripon Nestle site) City/State/Zip Ripon,CA 95366 Phone Cross Street Pine St APN 25904012 arProperty Owner* Ripon Unified School District Phone (209)599-2131 Address 364 N Acacia Ave City/State/Zip Ripon,CA 95366 oo+C-57 Contractor Geocentric Drilling,Inc. License# 1073146 Phone (916)304-2665 Address 1980 S River Rd.Suite E City/State/Zip West Sacramento,CA 95691 amConsultant/Sub-Contractor Haley&Aldich,Inc. License# Phone (949)554-4566 Address 426 17th St.Suite 700 City/State/Zip 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 65&70 feet ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 6 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS schedule 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: 2-inch Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 58,63' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ® OTHER 2 piezometer well jo OTHER: sonic GROUT SEAL PUMPED? O Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs PZ-01 &PZ-02 GROUT SPECIFICATIONS tremie placed neat cement grout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED none ❑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 ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: eby certi that I am authorized to complete this application and that the work will be done in accordance with S o uin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company APM Haley&Aldrich Print Name Cameron Paez Date 7/11125 DEPARTMENT USE ONLY i 1 Application Accepted By: \ Date Issued: ` `k L _ Grout Inspection By/Dates: �'�� il S Destruction Inspection By/Dates: Facili /Site Information FA Name ,►J,c 5�' .( (,�y. 1 w` FA Address 2� FA PE �� , WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: C� (7 : C Z�yY"l- ,GY S {'C�( `l �I't d"�L✓�i �� _� "� r f U h'z' y�Yv l�G ci WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'9 BY DATES 1 WELL PERMIT# INVOICE# Permit Z () ' 7 $179 x � ^� �� 1 t (7 W a'K cJ 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3 2O1 F 209 464-0138 1 www.sjcehd.com EHD 2M1 08-01-2024 Zp��r)'-) b Site Mitigation Well Permit Application