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+ <br /> SAN JOAQUIN Environmental Health Department <br /> "ILS�'•.' ;y�J —COUNTY— <br /> " / <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance, 1 <br /> with San Joaquin <br /> `` ppCounty Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address -a 2 0 <br /> Pi at 2( 0-1Kj ( A'.--) citylStatelZip RiponICA195366 Phone <br /> Cross Street 5 d-r APN Z <br /> Phone 209-599-2108 <br /> Property Owner* City of Ripon <br /> Address 259 North Wilma Avenue Licen lase#It 9938110 Phone 530-713-8783 <br /> RiponlCAl95366 <br /> C-57 Contractor Cascade DrillingTechnical Services <br /> icen <br /> Address 3000 Duluth Street CltylSlatelZip West SacramenlolCA.95691 <br /> Phone 510-495-5105 <br /> Consultant/Sub-Contractor Haley&Aldrich, Inc. License# <br /> Address 1956 Webster Street, Suite 300 CltylStatelZip Oakland/CA194612 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING ❑ HOLLOW STEM BORING DEPTH 1981eettws ❑BOLTEOTRAFFIC BOX ❑STOVEPIPE <br /> ❑EXTRACTION(VaporM'ater) ❑ HAMMERIDRNEN DIA.OFBOREHOLE 8inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑SOILVAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS NIA TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> 91 SOIL BORING [IPUSH POINT(GPI CPI) CONDUCTOR CASING ❑Yes ®No TBoring <br /> MIEITYPETO BE USED: ❑�GERS ❑HOSE ❑PIPEng Depth: <br /> ❑ INJECTION(Ak So O-1 [IHANDAUGER GROUTSEALDEPTH <br /> ❑ OTHER I� OT ER: Sonic GROUT SEAL PUMPED? ®Yes 1_qItNo (NOIEMauI um Freeefai DDepthh330Ftj P <br /> WELUSOILBORING IDS HP .� <br /> GROUT SPECIFICATIONS N'I OL�T �r <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD- (CHECK ALL THAT APPLYI <br /> if WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feel below surface <br /> TROUTEMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel belay sudace a feel below surface if>3 feel <br /> COMMENTS: <br /> 1 hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> l�/� —Title/Company Project Manager, Haley&Aldrich, Inc. <br /> Signed - ��" <br /> Print Name Cheyenne Wa m' Date 2/1912020 <br /> DEPARTMENT USE ONLY <br /> Da r Is�red: <br /> Application Accepted By: / <br /> Grout Inspection By/Date <br /> Destruction Inspection By/Dates: <br /> Facilil (Site Information FA# �yc1�C(,�.I d PR# 1 1111. <br /> FA Name NRAe //,, FA Address V`.' J 1l ` <br /> FA PE 24 b V WP Reviewed By Work Plan Date Q�(.' <br /> ❑G-57 7 AUgwreatlon forother to Sign Permit ❑Workers Comp ❑Workers ComPWaivef ❑Eraoschment Permit ❑Access Agreement [I Lead Agency Approval ❑MFR hh <br /> COMMENTSICONDITIONS: ��(� r �! cyy\, f UJ I l "1 rn. a �- � r g WJ <br /> f�Ylzl � � tL A'y A�� Well musr� b� rill <br /> b <br /> WP TYPE PE I sc FEE INFO AMT REMITTED CHEECK# RF(; D BY DATE PERMIT INVOICE# <br /> Permit 9 t 1313 $152 X 3, _ \ .(- <br /> t. <br /> . cehd.com <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 F 209 464 site Mid ation well PenIApwl�aen f Z <br /> EHD 2941 0"147 <br />