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SIBN J0ACUIN Esivil°omyrientM Health Department <br /> RECEIVED <br /> t <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIq 1 0 2019 <br /> For Wells and Borings Used for Contaminant Investigations and Remediaa�t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVUyDEPARTMENTEALTH <br /> -vr ,AN <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 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address Locust Avenue CitylStatelZip Ripon CA 95366 Phone <br /> Cross Street NIA APN <br /> Property Owner City of Ripon Phone (209-599-2108 <br /> Address 259 N Wilma Avenue City/state/Zip Ripon,CA 95366 <br /> C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street CitylStatelZip West Sacramento,CA 95691 <br /> ConsultantiSub-Contmctor ECM Consultants/Haley R Aldrich License# Phone 661-255-2798 <br /> Address 3526 Hyland Avenue CitylStatelZip Costa Mesa, CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: ORsite BoringsAVeils Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CON STRU TION SPECIFICATIONS <br /> MONITORING �0 HOLLOW STEM BORING DEPTH 2b. test 68m BOLTEDTRAFFICBOX ❑STOVE PIPE <br /> EXTRACTION(VapodWeta) ❑ HAMMERIIXaVEN DIA OFBOREHOLE . ' inch [I MULTIPLE CASINGS[I MULTH.EVELWELL CASING CIA <br /> SOILVAPORPROBE E3 MUD ROTARY CASINGTHICKNESS—��—TYPE OF CASING: (I STEEL ❑PVC ❑ OTHER <br /> SOIL BORING ­11-6 PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes [3No BoAK Dia: Cash;Dia: Cas6g Depth: <br /> ❑ INJECTION(k epvw aawret ❑ HANDAUGFR GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS ?]HOSE O PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? [I Yes ❑No (Nola:Marinum FmdM DeW is 30 Fq <br /> WEW SOILBORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_fat <br /> WELL IDs ❑PRESSURE GROUT To depth of fcetbelfrM sudace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From Ito—feet below sudace <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet belfsW surface or fast below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this appllcatlon and thatthe work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable Callfornto laws. <br /> Signed UJ ,Aln--- T81e/Company Program Manager, ECM Consultants <br /> Print Nam�inayak AChafys Date July 3,2019 <br /> I EPARTMENT USE ONLY <br /> Application Accepted By: �� _ Date Issued: 7/ �T <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Fac I /Site Information A �1 <br /> FA Name -� � FAAddress o IV_d�� FA# P1U{ V [ )� <br /> FA PE =1 WPReviewed By ��{( — Work Plan Dale v <br /> 7 ❑CS/Aulhorize (a 0laer b50n PaTA WMetsCanp ❑Wodrers OampWaira tPeil ❑pawsAoisowm Age AI;waI FR <br /> COM ENTSICONDITION // V <br /> �, / b, <br /> WP TYPE PE SC y'bt FEE I&0 JAMT REMIT TEDI CHECK# RECWD BY I DATE I - WELL PER i T## I INVOICE# <br /> Permit n 152 x I 2 <br /> 1868 E. HaEelton Avenue I Siockton- Gairfornia 95205 t 209 468-3420 f F 09 464-0138 1 www.sicefid.corn <br /> END' 0108,01-17 Sne MafOxlbAWee Pefine Applkafion <br />