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a <br /> SAN JOAQUIN Environmental Health Department <br /> �3 i � <br /> COUNTY— <br /> c,r ?/ 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,Deevelopment Title,Chapter 9-1115.3. and the San Joaquin County Well Standards. <br /> Elm Ave N,e&r V4 /J 4 `�- City/StatelZip Ripon CA1953666 Phone <br /> Job Address APN ZS°I O o Jz��"�,'� <br /> Cross Street Pine St Phone 209-599-2108 <br /> Property owner' City of Ripe <br /> 259 North Wilma Avenue CitylStatelZip RiponlCAl95366 <br /> Address License# 938110 phone 530-713-8783 <br /> C-57 Contractor Cascade Drilling Technical Services <br /> 3000 Duluth Street CitylStatelZip West SacramenlolCA.95691 <br /> Address <br /> Phone 510-495-5105 <br /> ConsultanVSub-Contractor Haley&Aldrich. Inc. License# <br /> Address 1956 Webster Street, Suite 300 <br /> CitylStatelZip Oakland/CA/94612 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 198 feet Ens ❑BOLTjpUEASINGSX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE flinch ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑STEEL❑asingae ❑ OTHER Casing Depth:� <br /> ® SOILBORING ElPUSH POIN, (GPI CPT) CONDUCTOR CASING ❑Yes ®No REMIE Boring ITYPETO BE USED: G AUGERS [IHOSE [IPIPE <br /> ❑ INJECTION 0 So None) ❑ HANDAUGER GROUT SEAL DEPTH <br /> ❑ OTHER L» OTHER Sonic GROUT SEAL PUMPED? Ed Yes q No (Note;M ' Freefall Depth is 30iF1) <br /> GROUT SPECIFICATIONS A/Oeu a A <br /> .y 0 " <br /> WELUSOIL BORING IDs HPA18 --Th— <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD' (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER ot_Inches to depth of feet <br /> WELL Me ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feetbelaxsurface <br /> ❑ <br /> MUSHROOM CAP ❑3 feel belay surface or feet below surface if>3 feet <br /> TREMIE TYPE TO BE USED El AUGERS ❑HOSE ❑PIPE <br /> COMMENTS: <br /> I hereby cetify that—I am authorized to complete this application and that the work will be done in accordance with <br /> r <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> � 11 ! TitlelCompany Project Manager,Haley&Aldrich, Inc. <br /> Signed Date 2/19/2020 <br /> Print Name Cheyenne We m <br /> D PARTMENTUSEONLY <br /> Date Issued: <br /> Application Accepted By: _ <br /> Grout Inspection By/Dates: .� <br /> Destruction Inspection By/Dates: e <br /> Facilit /Site Information Z a FA# v O 'f"� 1 PR# <br /> FA Address — � <br /> FA Name N / A <br /> 2 WP Reviewed By /\ Work Plan Date ►t�L- 2�(q } <br /> FA PE UUU <br /> ❑C-57 7 Authorization tonOther to Sign Permit ❑Workers COMP ❑Workers CompWaner ❑Encroachment Peimil ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: <br /> WP TYPE PE SC FEE INFO ANT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 29oy, $152x -1 Jb CL Q W <br /> 1868 E. Hazelton Avenue I Stockton, California 95206 i T 209 468-3420 F 209 464-s eMlgalon Well Perm Ap�I�b om <br /> EHD 29-01 OMI-17 <br />