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SAN JOAQUIN Environm enza! iiea.tvl Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _kvi Anne Foy e ' All t., r, - Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This application is made in compliance Win San Joaquin County Development Title,Chapter 9-1115.3.and the San Joaquin County Well Standards. Job Address South of 4t street and east of Walnut Avenue City/Statelzip Ripon CA 95366 Phone Cross Street NIA APN Property Owner- City of Ripon Phone (209-599-2108 Address 259 N Wilma Avenue City/StatelZlp Ripon,CA 95366 Cascade Drilling Technical Services 938110 916-366-1169 C37 Contractor 9 License# Phone Address 3000 Duluth Street Cltylstatelzip West Sacramento,CA 95691 ECM ConsultantslHaley&Aldrich Phone 661-255-2798 ConsulWnNsub-Contractor License# Address 3525 Hyland Avenue ClImIstatelzlp Costa Mesa CA 92626 CONSTRUCTION WORK TO BE PERFORMED: *Note: OHaite BodngsWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORINGBORMG pE st%s ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION LV8p0rN1aW) ❑ HAMMERDRIVEN DIA.OF BOREHOLE _7 inch [I MULTIPLE CASINGS[]MULT14EVFLWELLCASING DIA ❑ SOILVAPOR PROBE [i MUDROTPRY CASINGTHICkNESS�W�—TYPEOFCASING: ❑STEEL ❑PVC ❑ OTHER 9 SOIL BORING -[r1 PUSH POINT(GPICPT) CONWCTORCASING ❑Yes ❑No W09I a Ca hg Oa: Ca Inu Depth ❑ INJECTION(Aisoaa.rnu,e ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOSE USED ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED) ❑Yes -]No (Note:hunknum Freerel Depth is 30 Fq WEW SOR BORING IM GROUTSPECIBCATIONS DESTRUCTION WORK TO BE PERFORMED• STRUCTION METHOD-(CHECK ALL THE 6EPLYI #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth oI WELL IDs ❑PRESSURE GROUT To depth of faelbebw surface GROUT SPECIFICATIONS ❑EXPLOSIVES Fran_to_feet balm surface TREMIETYPETO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3teet below surfaces feel belaxsudace if>3 feet COMMENTS: {hereby certify that I are authorized to complete this appllcation and ihatthe workw111 be done In accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signetl f�y1 Title/Company Program Manager, ECM Consultants Print Name Binayak Acharya Date July3.2019 DEPARTMENT USE ONLY Application Accepted By: soC4— Date Issued: . 7-S-/9 Grout Inspection By/Dates: V. - r r Destruction Inspection By/Dates: Facli /Sltel form ton FA Nam ` r LMROMMewedBy .ti s✓.s�ri 41W 1.Z FA# dO if ss l,-p' FA PE -�� s Wafc Plan Dale ❑C57 9rCb7AutlwrbaJMI rOlhert)Sign Pamd OWCOWSCamp ❑Waters ConpWeI F.fEnaaachmenlpermg ❑A¢ &A.greanenl BoCead Agency Approval FR COMME NT5ICONDITIONS: W PTYPE PE SC FEE INFO AMT REMITTEp CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit s 1 3/3 $162 x 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 i F 209 464-0138 a1 Www,p.sicelld..ccorr EMD2 iGael-tr She