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jI -I Department RECEIVED SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and RemediationjUL 10 2019 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH r . o:r`... r'+:tt(yrs.:? fl�a,.:.. t=-,c, r'n6 t=.�lg A?' !`•"S:a CtaC i,T,t_ DEPARTMENT t-:.c: Application Is hereby made to San Joaquin County for a permit 10 construct and/or Install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address South of 4t streetan y d east of Walnut Avenue Cit /State/zip Ripon CA 95366 Phone Cross Street NIA APN Property Owner- City of Ripon Phone (209-599-2108 Address 259NWilma Avenue Cltylstatelzip Ripon,CA 95366 C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 Address 3000 Duluth Street City/state/Zip West Sacramento,CA 95691 Consultant/Sub-Contractor License# ECM ConsuftantstHaley R Aldrich Phone 661-255-2798 Address 3525 Hyland Avenue CltylState/Zip Costa Mesa CA 92626 CONSTRUCTION WORK TO BE PERFORMED: `Note: OBsite BoringsfuVells Require Access Agreements or Encroachment Permits TYPE OF WELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATION10 S MONITORING ❑ HOLLOW STEM BORINGDEPfH 25-5feei bg®BOLTED TRAtFICaOX ❑STOVE PIPE FXTRACTION(VapwAasil ❑ HAMMERMRIVFN DIAOFBOREHOLE Inch ❑MULTIPLE CASINGS❑MULTI-IEVELWELLCASING DIA ,itSgLVAPOR PROBE MUD ROTARY CASINGTHIGCNESSNJA TYPE OFCASING: [I STEEL ❑PVC ❑ OTHER' [I SOIL BORING PUSHPOINT(GPICPT) CONDUCTORCASING ❑Yes ❑No BMN Die: Caring Do' Casing Depth: ❑ INJECTION rAFsoaueomrer ❑ HANDAUGER GRWTSEALDEPTH TREMIE TYPETO BE USED, ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Mla Matlaan I Moral Depth 1530 FQ WEW SOILBOWNGICs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of,feel WELL IDs ❑PRESSURE GROUT To depth of_feet belax surface GROUTS PECIFICATIONS ❑EXPLOSIVES From_to_feet belmsurhce TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOMCAP ❑3 feat below surface or feet balm surface if>3 feel COMMENTS: I hereby certify that 1 am authorized to complete this apP6cation and that thew ork will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed ffT i1 Title/Company Program Manager,ECM Consultants Print Name — P kayak Acharya Date July 3,2019 DEPARTMENT USE ONLY Application Accepted By: Date Issu -7/k �1 Grout Inspection By(Dates: ^ ho 0 Destmction Inspection By/Dates: F I /S to I tormatio `` E� l ^'7 FA Name FA Address FAR ZS�N PRR on FA PE a U Win Reviewed By Work Pion Date C51 ❑ AuOarvabonfor011w to Sign Permit wnries Comp ❑Wmtars pWaver a"omhff*MPerme ❑AccassAgramrcnl Apparel MFR COM ENTSICONDITIONS: T ( VP �A-4 h� tjJA 1( bIjl QW— : fVj IWPTYPEI PEI SC I FEE INFO JANIT REMITTED I C RECV'D BY DATE . 1'nW�EELL PERMIT9 INVOICE# Permit 152 x # I O 0 1868 E. Hazelton Avenue i Stockton. California 9520 1 T 209 468-3420 i F 209 464 011M�welN.sic phd.corr EHDB 01 06-01-19 Silo