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SAN ! OAQUIN v rrvylreinmentai Health OePaftiffl ent <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 /> !� . ._`.G:d 4T;t;:a's".;vf} 2i£OriC.6- :`:'.< Sis�t f.�•y tt;i`s_ ';15;30:`.:EL"1� <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 Tille, Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address <br /> Walnut Avenue City/Statelzip Ripon CA 95366 Phone <br /> Gross Street <br /> N/A APN <br /> Property Owner' City of Ripon Phone (209-599-2108 <br /> Address 259 N Winne Avenue City/Statelzip Ripon,CA 95356 <br /> C-57 Contractor <br /> Cascade Drilling Technical Services Licensef/ 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street City/Statelzip West Sacramento,CA 06697 <br /> Consultant(Sub-Contractor ECM Consultants/Haley&Aldrich License# Phone <br /> 661-255-2798 <br /> Address 3525 Hyland Avenue City/State2lp Costa Mesa CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offske Bodngs/Welis Require Access Agreements or Encroachment Permits <br /> TYPEOFWELIJBORING NUMBER INSTALLATION TYPE C011 UCTIONSPECIFICATIONS <br /> Q MONTOPoNG ❑ HOLLOW STEM BORING CEPTH 45 feet bgs 0 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EKTRACTION(VWWaler) ❑ HAMMEWMWN CIA.0FBORF14OIE 9inrh ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING CIA <br /> Tat SOIL VAPOR PROBE LST MUDROTARY CASINGTHrCKNESS 'f — TYPEOFCASING: QSTEEL QfNC ❑ OTHER <br /> �L SOIL SMUG �_LI PUSH PORTION CPT) CONDUCTORCASING ❑Yes Otb Mario Da: Casrtg Da: Casio Depth: <br /> ❑ INJECTION rAieoaexo,, ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED ❑AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEALPUMPED7 ❑Yes ❑No (Nn1e MWknum Freefal Depth Is 30 TO <br /> WELOSOIL BORING 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^(set <br /> WELLIDS ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS [I HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> OMMENTS: <br /> 1 hereby certity that 1 am authorized to complete this application and that the work wilt be done in accordance with <br /> ,`� San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed — kA,) ---- Title/Company Program Manager, ECM Consultants <br /> Print Name Binaya Acharya Da1e July 3, 2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: N/W-'4�54" Date Issued: 7— % 77 <br /> Grout Inspection By/Dales: ,,,,,,,.✓ q <br /> Destruction Inspection By/Dates: <br /> acilf /Site Information <br /> FAName DWG V6,0 FAAddress O ��,e�„/Ar„L FAR zf35-s PR# SVyGo <br /> FA PE ��� WP Reviewed By AArSE � Work Plan Date <br /> ❑C57 R`liiAKWSComp ❑weriets CompW" PrEnuoachment PermR ❑AttassAgreement 0LeaJAgemy ApploM RITFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 7.q0� ;(j $152x L 3d/'c0 acT ,1/► WoW32 7g <br /> 1868 E. Hazelton Avenue I Stockton, California 952061 T 209 468-3420 F 209 464-0138 1 www.Giceho.con <br /> Eno 2 l 09-01-17 site MUgaaal wea PMna Appafa6011 <br />