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1 I <br /> S A I i r A 0 11-11 N �E--nifironmental Hsaith Department <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 /> t^r L-6.ved Fur AU <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 Locust Avenue CitylStatefZip Ripon CA 95366 Phone <br /> Cross Street NIA APN <br /> Property Owner' CBy of Ripon Phone (209-599-2100 <br /> Address 259 N Wilma Avenue Citylstatelzip Ripon,CA 95366 <br /> C-67 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street City/Statel2ip West Sacramento,CA 05691 <br /> ConsultantiSub-Contractor ECM Consultants/Haley&Aldrich License# Phone 661-255-2798 <br /> Address 3525 Hyland Avenue City/State2lp Costa Mesa,CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: ORsile BodngsiWells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORItK,DEPTH 4fi eat 1395 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION vapor/Wated ❑ HAMMERURVEN DIA OF BOREHOLE 2inch ❑MULTIPLE CASINGS[I MULTILEVEL WELL CASING DIA <br /> �nJ SOILVAPORPROBE Q MUD ROTARY CASING THICKNESS " TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ICI SCILBORING -- PUSH POINT(GPI CPI) CONDUCTORCASING ❑Yes ONo Boring Do: Casing Die: Gwiv Depth: <br /> ❑ INJECTION u.sow..omwt ❑ HANDAUGER GROUT SEAL DEPTH TPEMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUTSEALPUMPED7 ❑Yes ❑No (Nob:Madnum Freefal Depth is 30Ft) <br /> WELD SOIL BORING Me GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) <br /> #WELLSTOBE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feet <br /> WELL IDS ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSMES From_to_feet beiowsudace <br /> TREMIE TYPE TO BEUSED ❑AUGERS [I HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet Wowsudace or feet below surface If>3 feet <br /> COMMENTS: <br /> I hereby certify that I 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 /> Signed /JT--:, f w.-� Title/Company Program Manager,EGM Consultants <br /> Print Name Elmayak Acharya Date July 3, 2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: ski.— A, ,—gp Date Issued: 7—Jr—If <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates- L'L""' � � 0 <br /> FacillIvISHD Information <br /> FA Name �•M�f �L =KL FA Address Z � . y y� FWI dO if, � PR# OS �7",7 <br /> FA PE ��j (� VIP Reviewed By �F � Wack Plan Date <br /> ❑C57 2t-57AuthoraaWn fo'Other toS9n Pemn G7°#aWSOanp ❑WwWsCamp Wahw I+315mchmantPemvt ❑Amassfteement lead AIImApprwal gMER <br /> C OMMENTSICO N DfTION S: <br /> JWPTYPEJ PE I SC I FEE INFO JAMT REMIT-rEDI CHECK# I RECVD BY I DATE WELL PERMIT# INVOICE# <br /> Permit I Zjeurr' I ya 152x ,11'/0•Oc-� z`t 74 1 W"r' Yr/! WOW 3 7 ST <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T' 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> PHD29ot oe-ot-n She wcgatnnwdl PermitApgceuan <br />