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O oUIM t <br /> SAN -JOAQUIN 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 <br /> San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address Ja (reel QA/` J` N ry %4 City/State/Zip Ripon/CA195366 Phone <br /> Cross Street at intersection with Nor APN <br /> Property Owr%P City of Ripon Phone 209-599-2108 <br /> Address 259 North Wilma Avenue City/State/Zip Ripon/CA/95366 <br /> C-67 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street City[State]Zip West Sacramento/CA.95691 <br /> Consultant/Sub-Contractor Haley&Aldrich, Inc. License# Phone 510-495-5105 <br /> Address 1956 Webster Street,Suite 300 City/State/Zip Oakland/CA/94612 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ONsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 25.5feetbgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMiller) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> E1 SOILVAPORPROBE 1 SVP ❑ MUD ROTARY CASINGTHICKNESS NIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING RI PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ®No Boring Dia: Casing Dia: Gasing Depth: <br /> ❑ INJECTION Ws*".o net ❑ HANDAUGER GROUTSEALDEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No IN [ Maximum Freetall Depth is IT) , / f <br /> WELDSOIL BORING Ins SV-122 GROUT SPECIFICATIONS 94ao s: O� IS 'Q.YI�t� <br /> cl 1 AA I� rugir rRill I <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL IDS ❑PRESSUREGROUT Todepihof_feelbelowsudace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> I 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 /> jj//`` Project Manager, Hale &Aldrich, Inc. <br /> Signed � � // /S%ie �— Title/Company 1 9 Y <br /> Print Name Cheyenne Wa6WjK Date 1/1412020 <br /> JJEP TME NT USE ONLY ^ O <br /> Application Accepted By: Date Issued: G <br /> ab <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: l! <br /> Facillt /Site Information gyp. <br /> 15 <br /> FA Name N ,� ,Q, VS FAAddress 2�0 `f/`r FAO B� <br /> 29 Work Plan Date dR W <br /> FA PE WP Reviewed By I <br /> ❑G-57 C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permil ❑AocessAgreemenl ❑Lead Agency Approval ❑MFR <br /> COMMENTS NDITIONS GI 447 N/ W 1A� S d' Y.G. <br /> sc lKu, b�� y 1 $ ,«, S = ;9 I" b <br /> WPTYPE PE SC FEEINFO AMT REMITTED CHECK# RECV'DBY DA TE WlELL PERMIT# INVOICE# <br /> Permit �01 3 t3 $152 X 30 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-01138a1 Mitigation <br /> .s cehhd..om <br /> EHD29-0113"1-17 sitp,x-,� <br /> Slf� 8048fl <br />