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SAN: JOAQUIN Environmental Health Department —COUNTY— er�s r 5=��,rrotz<oti Greotness grows here. 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 48 Hours Advance Notice Required For All Inspections 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 San Joaquin County Well Standards. Job Address W 4th Slreel City/State/Zip Ripon/CA/95366 Phone Cross Street west of intersetion with S Locust Ave APN 25 7 ze)�1 Property Owner' City of Ripon Phone 209-699-2108 Address 259 North Wilma Avenue City/State/Zip Ripon/CA/95366 C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 Address 3000 Duluth Street City/State/Zip West Sacramento/CA.95691 Consultantsub-Contractor Haley&Aldrich, Inc. License# Phone 510-495-5105 Address 1956 Webster Street, Suite 300 City/State/Zip Oakland/CA194612 CONSTRUCTION WORK TO BE PERFORMED: *Note: OHsile BoringsM/ells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 25.5 feet bps ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapoirMster) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2iwh ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOILVAPORPROBE IHPJ_1 SVP ❑ MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER ❑ SOILBORING El PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes ®No Bodlg Dia: Casllg Dia: Casing Depth: ❑ INJECTION IAt Soaae Ozrcal ❑ RANDAUGER GROUTSFALDEPTH THEME TYPE TO BE USED: ❑AUGERS OSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [RIyej ❑No Note:Ma knum Freefall Depth is 30 Ft) /� (A-) f WELIJ SOIL BORING IN SV-124MP-124 GROUT SPECIFICATIONS T `- DESTRUCTION WORK TO BE PERFORMED: DESTRI ION METHOD: (s(CHECK ALL THAT APPLY) C #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of_feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. SignedP. ,e AIVAM - - Title/Company Project Manager, Haley&Aldrich, Inc. Print Name Cheyenne Wa Date 1/14/2020 D ARTMENT USE ONLY n /� /�a Application Accepted By: LA Date Issued: Z J Grout Inspection By/Dates: '/ Destruction Inspection BylDates: �- `� D Facilit /Site Information FA Name 45 FA Address -to (,� C FA# DD PR# 3- FA PE WP Reviewed By I-6k/ Wok Plan Dale Pf f ❑G-57 C-57 Auhmdzalbn for Other to Sign Prmil ❑Workers Comp ❑WOAers Comp WaNer ❑Emroachmenl Permit ❑Access Agreement ❑Le ad Agency Approval MFR COMMENTS/ NDITIONS' r U ft ,s� �Ju twNa-(' beLd:L�(v+yed u4•l.eJr P � 3tW.- t la WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit -1 �' 3113 $152 x � C. C, I � I /o/zol w Peo 1868 E. Hazelton Avenue I Stockton, California 95205 l T 209 468-3420 1 F 209 464-0138 1 WWW.sjcehd.coln END 28-010eO1-17 Site Mlugatbri Well Permit Application s li2oo $o Ct 9b