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RECEIVED 1 <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and RemediatiML 10 2019 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRUNMtNTAL HEALTH <br /> y. F:-: -,:'i_<:{ e t k:! _";,.-•.,5_:,.e `al>. G.: i •S S -' DEPARTMENT <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 Walnut Avenue City/State/Zip Ripon CA 95366 Phone <br /> Cross Street N/A APN <br /> Property Owner' Cilyof Ripon Phone (209-599-2108 <br /> Address 259 N Wilma Avenue City/Statelzip Ripon,CA 95366 <br /> C57 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 ECM Consultants/Haley&Aldrich License# Phone 661-255-2798 <br /> Address 3525 Hyland Avenue City/State/Zip Costa Mesa CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ONsite BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIRCATIONS <br /> MONITORING 0 HOLLOW STEM BORINGDEPTH 25.5 feet 139121 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> EXTRACTION(VepaM'ater) ❑ HAMMERNRNEN DWOFBOREHOIE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> SOILVAPORPROBE MUD ROTARY CASINGTHICKNESS—WA TYPE OF CASING: O STEEL O PVC O OTHER <br /> [I SOIL BORING PUSH POINT(GPICPI) CONDUCTORCASING ❑Yes ❑NO SOON Dia: Casing Die: Casing Depth: <br /> ❑ INJECTION(Aisoaoe.omnee ❑ HANDAUGFR GROUT SEAL DEPTH TREME TYPE TO BE USED. GAUGERS (3 HOSE OPIPE <br /> ❑ OTHER ❑ OTHFTE GROUT SEAL PUMPED? ❑Yes ONo (Nola MexinmImefell Depth is30F0 <br /> WEW SOILBORINGIDs GROUT SPECIFICATIONS <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 feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feel belm surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surlace <br /> TREMIE TYPE TO HE USED AUGERS ❑HOSE El PIPE ❑MUSHROOMCAP ❑3 feet below surface test below surface 9>3 feet <br /> COMMENTS: <br /> 1 hereby certify that am authorized to complete this application and that the work will be done In accordance with <br /> fl San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �'f I„L—�� TNe/Company Pram Manager, ECM Consultants <br /> Print Name Binayak Acharya Date July 3,2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facllil /Site Information <br /> FA Name FAAddress FA# �� PR# OS�/S�iv7 <br /> FA PE L 0 WP Reviewed By Work Plan Date 6 <br /> C3? OCfJ7AUlhplftdean for Otlterto Sign Permit eYs Carp ❑Walrefs Can Wainer IPSmt OAOOessAgmemshl atl Apprm9f MFR <br /> COM ENTS/CONDITION : C✓P dp j cvav <br /> JWPTYPEJ PE I SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit �'1 152 x v30 3 ? A (� 7j- g <br /> 1868 E. Hazelton Avenue I Stockton. California 952051 T 209 468-3420 1 209 464-0138 1 VVWw.sjceha-cc m <br /> END 2941 eae147 Site MNgtGon Well Pemul Appicanon <br />