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SAN JOAQUIN Environmental Health 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 /> -. .. c. . '1i:' J /:SO 8,1 pp+. .�. <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 Tithe,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address Second Street City/Statelzip 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-67 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street City/Statelzip West Sacramento,CA 95691 <br /> Consultant/Sub-Contractor ECM Consultants/Haley&Aldrich License# Phone 661-255-2798 <br /> Address 3525 Hyland Avenue City/statelzip Costa Mesa CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsfle BodngslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS <br /> ❑ MONTORING ❑ HOLLOW STEM BORING DEPTH 45 feet bills Q BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapulWaler) ❑ 14AMMMMVEN DIA.OF BOREHOLE M 9 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING WA <br /> p SOILVAPORPRODE MUDROTAR/ CASINGTOCKNESS "" TYPEOFCASING: ❑STEEL ❑PVC Q OTHER <br /> I� SOILBORING PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Soft Da Cmkg Da: CaNV DMIN <br /> ❑ INJECTIONWsoamomrol ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes [I No (Nola MaAm m Fredall Depth is 3oFQ <br /> WFUJ SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALLTHAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVERBORE DIAMETER of_inches to depth of_feel <br /> WELL IDs ❑PRESSUREGROU7 Todepthoffeetbe'.oxsurface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feetbelowsurfam <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface it>3 feet <br /> COMMENTS: <br /> 1 hereby certify that 1 am authoylaed to complete this application and that the walk will he done in accordance with <br /> A San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 92 ,i Title/Company Program Manager, ECM Consultants <br /> Print Name 13mayak Acharya Date July 3,2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: nn <br /> Destruction Inspection By/Dates 'Q <br /> FacilltvISIte Information <br /> FA Name M,A '41ille- vSw FAAddress Z30 S s �n,l./ql� FA# �Zfjsr PR# <br /> FA PE f&O WP Renewed By _ Work Plan Dale <br /> ❑Cb7 9r&67Auamd9wFor01hslo Sipe Pemit Grftkees Comp ❑Workers Comp Wdwr 1YEncro30m tPermil ❑Att Agreement 6j1e6d Agency AppmrdZMFR <br /> COMMENTSICONDITIONS: <br /> WP TYPE PE I SC FEE INFO (AMT REMITTED1 CHECK# RECV'D BY IDATE WELL PERMIT# INVOICE# <br /> Permit 290,E 130 $152x / /000 Z&AIT 44 7-r-il <br /> 1868 E. Hazelton Avenue j Stockton, California 95205 j T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.corn. <br /> EHD 2901 efi01-17 Sm MMgaWn Wes Penn Applicatgn <br />