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RECEIVED <br /> k' <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> �� 1 U �019 <br /> For Wells and Borings Used for Contaminant Investigations and RemedENVIRONMENTAL HEALTH <br /> 1 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEPARTMENT <br /> -Q ;�..., r:::-. ... v�.,•-.- n G'o- 'E:e� ="i3: .�`cc`e ;;�ue14.:1-j�nr <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 /> Job Address On City Parking lot west of Industrial Avenue CitylStatelZip <br /> Ripon CA 95366 Phone <br /> Cross Street NIA APN Phone (209599-2108 <br /> Property Owner' City of Ripon <br /> 269 N Wilma Avenue CltylstatelZip Ripon,CA 95366 <br /> Address 916J88-1169 <br /> Cascade Drilling Technical Services License# 938110 Phone <br /> C-57 Contractor West Sacramento,CA 95691 <br /> 3000 Du1Wh Street CitylStateZip 661-255-2798 <br /> Address Phone <br /> Consults lisub.Contractor <br /> ECM GonsultantslHaley&Aldrich License# <br /> CitylStatelZip Costa Mesa CA 82626 <br /> Address 3525 Hyland Avenue <br /> CONSTRUCTION WORK TO BE PERFORMED.*Note: Offate Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPEOFWEWB RI UMBE INSTALLATION TYPE rONSTRIJ )N SPECIFICATION <br /> ❑ HOLLOW STEM BORING DEPTH 'p 1O°`b9P7 MBOLTFDTRAFFIC <br /> IINGS X ❑STOVEPIPE <br /> CASING <br /> L!ONRORING DIA OF BOREHOLE jOrdl—❑M�TIPLE CASWGs❑MULTI"LEVEL WELLCASING OA <br /> RACTION(Vapodw3teg ❑ HAMMERIORNEN CASING41A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> LVAPORPROBE [� MUD ROTARY Casing Dia: Casing Dark. <br /> LBBIa 9 PUSHpCINT(GPICPT) CONDUCTOR CASING ❑Yes ❑No TBodg AREMIE PE TO REUSED. ❑AUGERS ❑HOSE ❑PIPE <br /> tA' °a o�mer ❑ WWDAUGER ROUT SEAL PGROUT SM PUUMPHED7 ❑Yes ❑No (Note MaiNnum Finahat Depth is 30 Ft) <br /> ❑ OTHER ❑ OTHER <br /> WEW SOIL BORING IDs <br /> GROUT SPECIFlCATION$ <br /> DESTRUCTION NIMDO•ICHECKALL THAT APPLY) <br /> DESTRUCTION WORK TO BE PERFORMED_: COVER-BORE DIAMETER of_inches to depth of—feet <br /> #WELLS TO BE DESTROYED OPRESSUREGROUT To depth of__feet belowsurtam <br /> WELLIDs ❑EXPLOSIVES From_,_to_feet below sulfate <br /> GROUT SPECIFICATIONS <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP - 3 feet below sudace or feel below surface if>3 feet <br /> COMMENTS: <br /> 1 hereby eeAify thatl am authorized to complete this appgeatlon and thattheworkw111 ha done in accordance vlith <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> I� Title/Company Program Manager, ECM Consultants <br /> Signed !/�� <br /> Binayak Acharya Date Juty3,2019 <br /> Print Name <br /> RTMENT USE ONLY <br /> • Date Issu ' <br /> Application Accepted By: <br /> Grout Inspection BylDales: Ica g <br /> Destruction Inspection By/Dates: <br /> F loill 1 to <br /> Info oration <br /> FA Name N FA Address Q FARrj�,S — PR# <br /> FA PE ` <br /> WP Reviewed By k Work Plan Date - <br /> ❑C57 Aulhaizagwfix OhartoSign Pemat Woriaescomp ❑WMcers CanpWaiver EnaoaManlPermil ❑Aaess Agreement Age Appavai FR <br /> COM ENTSICONDITIONS: m S <br /> 5s.1 1x r hi✓ LI w,y it <br /> Wp TYPE PE SC FEE INFO AMT REMIZ� EC A V'D BY �DATE WELL PER INVOICE# <br /> Permit 162 x +^/ <br /> 1868 E. Hazelton Avenue ( Stockton, California 96205 j , SAO 209468-342 j F 2094640138anonv aeminygOsuCoon, <br /> EH020-010e a1-17 <br /> js�pS <br />