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,oPg t..g • SAN JOAQUIN COUNTY 0 FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP yl1AII < • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.or_qlehd UNIT IV 4�iF O•iR•` WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. City of Ripon sidewalk or curb ROW, Just east of 311 First Street,in sidewalk or curb City of Ripon Right-of-Way Site Location NW corner of First and Locust Cross StreetROW on west side of Locust City/State Ripon Zip 95366 APN Fncroachmam Pa.1t attached Property Owner City of Ripon Address 259 N.Wilma Avenue City/State Ripon Zip 95366 Phone 209-599-2108 C-57 Contractor Cascade Drilling, LP Address 3632 Omec CircleRancho Cordova 916-638-1169 City/State CA Pei42 Lic 938110 Phone Consultant/Sub Cntr ECM Inc. Address 3525 Hyland Avenue,Ste 200 City/State Costa Mesa,CA Lie 778024 Phone 714-662-2759 Billable Party Environmental cost Management.Inc. Address 3525 Hyland Avenue,Ste 200 City/State Costa Mesa,CA Zip 92626 Phone 714-662-2759 GIS Coordinates:X 6380527.1904 Y 2092113.7730 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs Monitoring Well M-55A ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 ® MONITORING ®HOLLOW STEM DIA.OF BOREHOLE B" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2" —0 EXTRACTION:Vapor/Water ❑HAMMER/DRNEN CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 2 R above screen TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE KI PIPE _0 SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Ie Air So,,,.0z,r,l❑HAND AUGER GROUT SPECIFICATIONS bentonite and cement(3-5% max bentonite) _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet bgs M BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dla: COMMENTS:RWQCB-Approved Work Plan sent to EHD on 11/08/12:Target screen interval between 105 to 120 feet bgs with 10'screen total. NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California laws. Signed �--- Title/Company Program Manager, Environmental Cost Management, Inc. Print Name BinaVak ACharya Date November 27,2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS L• JO /NDuo7 egN_ Wyd'l9 WORK PLAN DATED 2,o/ Z, APPLICATION ACCEPTED BY 1�CL(3'/GWn-� DATE F ^'t"" A GROUT INSPECTION BY FINAL INSPECTION BY Ru TE ii^fO-f3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE n REQUEST PR# $125, I I 0274 &f4,vT44- SR# C06 y 0 J 3 75 3 00 PR# 2900 C-57 WC Ll WAIVERn�p, C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT k, ENCROACHMENT DOC ✓ EHD 29-01 5/09/12 WELL PERMIT APP