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4' qu 11. N • ao.�r.coc • SAN JOAQUIN COUNTY —ate. ENVIRONMENTAL HEALTH DEPARTMENT LOP ` SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV N Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd —� . 4C%FOa:�P r WELL & BORING PERMIT APPLICATION C tfj�1r FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI,�TION� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED H)�r",,g,g,QNNC7�fj,,��''OOel(©", �� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is ade n'CAOevOytlk'iTtggllyryyan Joaquin County Development Tide,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department, ,>kFcc Multiple Citv of Ripon - See next two pages for location NP Site Location Right-of-Ways Cross Street information for each CPT boring City Ripon Zip 953^0^o APN Property " r Owner City of Ripon Address 259 N.Wilma Avenue Cit Ripon Zip 95366 Phoney 209-599-2108��-- C-57 Contractor Address= ` -�' Address CC it. City9 p'Lic ,�Phone X55�+i 9 8 Consultant/Sub Cntr v.i - Address 3525 Hyland Avenue.Suite 200 City Costa Mesa Lic 778024 Phone 714-662-2759 io Billable Party cam, -^- Address 3525 Hyland Avenue.Suite 2017 Cil Costa Mesa 92626 y Zip Phone 714-662 2759 GIS Coordinates X - Y --- ► There are 19 proposed CPT borings. See next two pages for location information for each of the 19 borings. CONSTRUCTION WORK TO BE PERFORMED ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs There are 19 proposed CPT borings. See next two pages for name of information for each of the 19 borings ❑WELL IDs ❑OTHER IDs � f TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: .,_❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS __ TYPE OF CASING: El STEEL 11 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL t0 Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _,_,_®SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Ii.u.ArSuarae Omral❑HAND AUGER GROUT SPECIFICATIONS 5%bentonite and cement mix _❑OTHER: ❑OTHER APPROX.BORING DEPTH -125'or less ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boring Dia. COMMENTS:Exact CPT locations not identified in Work Plan.but field selected based on utilities and road access.See attached ma NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTIONMETHOD ICHECK 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 Fr BELOW SURFACE TREMIE TYPE TO BE USED: El AUGERS ❑HOSE [:]PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I 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 lf.�,.�,...pJ---�-- Title/Company Project Manager, Environmental Cost Management Print Name Binayak Acharya. Date September 1, 2010 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS D // WORK PLAN DATED t�vN'C�'rr,��/� APPLICATION ACCEPTED BY �'aAejl;WW__ �J/ DATE ISSUEED / / AREA GROUT INSPECTION BY Y dbrip IYIG1rbJItL.- 4-f$•/6 FINAL INSPECTIC/ { "� aySU1iy DATE _ DESTRUCTION INSPECTION BY DATE COMM ENTSICON D ITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE SERVICE RO# INVOICE REQUEST PR# Z OS $ 122x I if SR#DD60-1w 6 3 134(. bG y� 1 . Ro# 3500 29 o 6117 f C-57 WC _WAIVER C-57 LETTER OF AUTHORIZATION TO EHD 29-01 07/28/10 SIGN PERMIT ENCROACHMENT DOC O WELL PERMIT APP