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Locust Street Cross Street <br />Job Address 201 W. 5th Street city/State/Zip Ripon, CA 95366 Phone <br />APN 259-35-013 v"-- <br />209 -480 -4663 <br />Property Owner* FJJC Investments, Inc. c/o Judi van Riet Phone <br />Address 1408 W. Main Street, #C <br />C-57 Contractor V&W Drilling <br />City/state/Zip Ripon, CA 95366 209 -469 -7700 <br />License# 720904 Phone <br />Address 3806 Duck Creek Drive City/State/Zip Stockton, CA 95215 <br />msu;;Sub.ContraCa Kablanow, Ground Zero Analysis ....c -1;; (GzA) PG 5234 Phone 209-522-4119 License# <br />3 # WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of______inches to depth of feet <br />waLINMW -1, MW-2, MW -3 El PRESSURE GROUT To depth of eet below surface <br />GROUT SPECIFICATIONS Neat Cement <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE laPIPE <br />EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP Mt 3 feet below surface or feet below surface if >3 feet <br />Signed <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Title/Company Professional Geologist/GZA <br />Raynold Kablanow Date 11/4/16 Print Name <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />DEPARTMENT USE ONLY <br />- 3 0 , 7 cA-n-ee 29c3 613 ...y/7 <br />EHD 29-01 10-26-2015 <br />.5.,166 .74,z9 3 <br />Site Mitigation Well Permit Application <br />Address 1172 Kansas Avenue City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spartie, Ozone( <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? <br />GROUT SPECIFICATIONS <br />DIA, OF BOREHOLE <br />CASING THICKNESS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 Yes 0 No Boling Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />COMMENTS: <br />DESTRUCTION WORK TO BE PERFORMED: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA# 00 23 74t 5 PR# OCli I Ii 3 1 <br />FA PE WP Reviewed By .1\ji ide c 14-.0,,d.e..-5c til Work Plan Date Aia 2, Zct le <br />0 C-57 Er6:57Authorization for Other to Sign Permit Vf‘rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement atad Agency Approval aloroff <br />COMMENTS/CONDMONS: 644., ,, rikm,„..) c e.tc„,,4- 0 e4,1,-- 4,5 0 i.-, tics , .d w , ti- firei44 ‘ C P .P .2 • AVVIO l-,e7t? ei;e4,/ 7/ 7/494 014.+44:te.4) I • 4 0440-4- T01.4 jot I MIA) Z. otc 4y peg-SSUre WC,i, r , Pe id pre.Sr‘Orr X.- jo Ad. ;et 1-di-e.S ,. Chised LOP 54-e <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REMIT BY DATE SERVICE REQUEST# INVOICE# <br />Permit 2)(52 313 $139x 3z // 7 - 3c i'71 C A-1-rt 5k cc 74 Z7 ),1 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 />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 Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />ot.5"uk., <br />•