Laserfiche WebLink
S AN J O AQ U I N Environmental Health Department <br /> —COUNTY- <br /> `� <br /> ,`;icrrot„o'% Greotness grows here. <br /> BORING PERMIT APPLICATION <br /> SITE MITIGATION WELL & <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 /> evelopment Title, Chapter 9-1115.3.an[t the San Joaquin <br /> This application is made in compliance with San Joaquin County D County Well Standards. <br /> CIlylStatelZtp RiponlCAl953i Phone <br /> Job Address 364 N Acacia Ave APN 0 = <br /> I s <br /> Z7�/ �/'/-� <br /> Cross Street W Main StreeUN Acacia Ave Phone 209209-59 <br /> Property Owner' Ripon Unified School District CltylStatertrp P R <br /> Address 364 N Acacia Ave 938110 Phone 530-71 <br /> 3-8783 <br /> License# <br /> C-57 Contractor Cascade Drilling Technical Services CitylStatelZip West SacramenlolCA.95691 <br /> Address 3000 Duluth Street Phone 510-495 <br /> -5105 <br /> ConsultanVSub-Contractor <br /> Haley&Aldrich, Inc. License# <br /> Address 1956 Webster Street, Suite 300 <br /> CilylStaleRip OaklandlCAl94612 <br /> Access Agreements or Encroachment Permits <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require <br /> TYPE OF W�ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH MULTIPLE CASINGS MULT4LEVELWELLCASING DIAL <br /> ❑ EXTRACTION ivaporMater) ❑ HAMMERrDRIVEN DIA.OF BOREHOLE BIn� ❑ Casing Dia: Casing Depth. <br /> ❑ SOILVAPOR PROBE 0 PUSH POINT CASINGTHICESS <br /> (GPI CPI) CONDUCTORKN SING NIA❑Yes ®No Boring DbCASING: El ❑PVC ❑ OTHER n <br /> MUD <br /> RI SOILBORING GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> HAND AUGER <br /> ❑ INJECTION( ezarel M OTHER: Sonic GROUT SEAL PUMPED? ®Yes ❑No (Hole:Maximum keefall Depth is w F — <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELD SOIL BORING IDS HP-119 <br /> DESTRUCTION METHOD' (CHECK ALL THAT APPLY <br /> DIAMETER of�inches to depth of feet <br /> DESTRUCTION WORK TO BE PERFORMED: OVER-BORE feel below surface <br /> #WELLS TO IE DESTROYED ❑PRESSURE GROUT To depth of <br /> WELL IDs ❑EXPLOSIVES From.to feel below surface <br /> GROUT SPECIFICATIONS ❑MUSHROOM CAP ❑3feel belox surfaceor feel below surface if>3 feet <br /> TREMIE TYPE TO BE USED ElAUGERS ❑HOSE ❑PIPE <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance w t <br /> San Joaquin County Ordinance Codes and Standards,panyll Project <br /> rer applicable California laws. <br /> /� TiilelCom an 10 ect Manager, Haley&Aldrich, Inc. <br /> �i jjJ <br /> Signed s Dale 211912020 <br /> Print Name Cheyenne Wa <br /> DEPARTMENT USE ONLY 77 <br /> OW D <br /> Dale Issued: - <br /> Application Accepted By: <br /> Grout Inspection BylDates: <br /> Destruction Inspection By/Dates: <br /> Faclltt (Site Information I , , FA# � '7 t�� PR# <br /> FA Address L✓ <br /> FA Name <br /> 'v\ Work Plan Dale <br /> FA PE O VIP Reviewed By <br /> ❑P57 G-57 Authorization for Other to S'gn Permit ❑Workers Come [I Workers Comp War ❑Encroachment Penh ❑Access Agreamenl ❑lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: <br /> WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY A INVOICE# <br /> WELL PER IT# <br /> Permit ZROS $152x ,3 lksb CC. <br /> cehd.com te Mitigation Well Permit Application <br /> Si <br /> 1858 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464 <br /> EHD 2e-01 09-0147 <br />