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f. <br /> �t11� 7 SQN J 0Q0U I N Environmental Health Department <br /> —COUNTY— <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 with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> CilylStatelZip Ripon/CA/95366 _Phone <br /> Job Address 435 N. Maple Ave. <br /> Cross Street W MainStreet/N Wilma Ave /lam C' ii APN Ale Phone 209-599-2155 <br /> � <br /> Property Owner• Ripon Chri Dan School CilylStatelZip RiponlCA195366 <br /> Address 435 N. Maple Ave. phone 530-713-8783 <br /> License# 938110 � <br /> C-57 Contractor Cascade Drilling Technical Services CItylStatelZip West Sacramento/CA195691 <br /> Address 3000 Duluth Street Phone 510-49510-495 <br /> -5105 <br /> Consultant/Sub-Contractor <br /> Haley&Aldrich, Inc. License# <br /> CItylStatelZip OaklandlCAl94612 <br /> Address 1956 Webster Street, Suite 300 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF TYPE OFW NUMBER❑ HOLLOW STEM <br /> TYPE BORICONSTRUCTION <br /> G DEPTH NSPEOIFICATI i9ofeefbgs IONS ❑BOLTED TRAFFIC BOX STOVE PIPE <br /> ®MONITORING <br /> ❑EXIRACTION(VaporM'aler) ❑ HAMMERIDRNEN CABIN BOREHOLE 8i^� TYE OFICASING: [3 STPLE CASINGS❑EEL❑PVC E❑ OTHERL WELL SING= <br /> ❑ MUD ROTARY CASINGTHICKNESS NIA Casing Dia: Casing Depth: <br /> ❑SOILVAPORPROBE ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®N^ Bonng Dla: <br /> ® SOILBORING GROUT SEAL DEPTH THEMIETYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ INJECTION(Akisa oz 1 ❑ HAND AUGER P <br /> [� OTHER: Sank GROUT SEAL PUMPED7 ®Yes Q No (Nola:MaxlmumoFreatall Dep�N 30 t <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELU SOIL BORING IDs HP-1171M-58C7 <br /> DESTRUCTION METHOD-icHECKALL THATAPPL feet <br /> DESTRUCTION WOR (TO BEPERFORMED: COVER-BORE DIAME TER of depihof <br /> #WELLS TO BE DESTROYED PRESSURE GROUT To depth of_feet below surface <br /> WELL IDs [I EXPLOSIVES From to—feet below surface <br /> GROUT SPECIFICATIONS MUSHROOM CAP ❑3feet below sudaosor feet below surface,if>3 feet <br /> TREMIE TYPE TO BE USED ElAUGERS ❑HOSE ❑PIPE <br /> COMMENTS: <br /> at I e done in accordance with <br /> iffl,sun OF <br /> I hereby cOR <br /> San Joaquin County rOrdinance Codes land Standaide lyds, and all other applicable California laws. <br /> Title/Company Project Manager,Haley&Aldrich, Inc. <br /> Signed ' 'V <br /> Che enne We Date 2/19/2020 <br /> Print Name Y <br /> DEPARTMENT USE ONLY <br /> Date Issued: J / <br /> Application Accepted By: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: I <br /> Facilit (Site Information 23b j FA# OO Z (541 f PR# 57 <br /> FA Address V f <br /> N `� " 5A .( WorkPlan Dale eo t I �Z <br /> FA Name ' ) <br /> FA PE v1 Zo WP Reviewed By❑C-57 U�CG57 AuNoriza6on for Other to Sign Peimil ❑Workers Comp []Workers comp Waiveerr <br /> ❑Endoachmenl Permit Aaess A9reemeni [I Lead Agency Approval ❑MFR <br /> COMMENTSfCON TIONS* my <br /> Q W $r6 <br /> V`•CCU <br /> fiM.Otf • b 0 rt( o ivy <br /> WELL PERMI # INVOICE# <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV`D Y D 001 f 0 3 <br /> Permit Z901 I $152x 3. C. T <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 46 -0138 sjcehh .uon <br /> Site Miegalion WeA Permit Appllragon <br /> EHD 29O1 OB-01-17 <br />