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SAN4JOAQUIN Environmental Health Department —COU NTY Greatness 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 S Walnut Street ROW (uA!310 I11L7 � Citu ryistate/Zip RiponICA195366 Phone Cross Street north and south of intersection with 4th Street APN 513 Z� IQ Phone 209-599-2108 Property Owner` City of Ripon Address 259 North VJilma Avenue City/StatelZip Ripon/CA/95366 C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 Address 3000 Duluth Street CitylStatelZlp West Sacramenl01CA.95691 ConsultantlSub-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: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 25.5feelbgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERORIVEN DIA.OF BOREHOLE 2inch ❑MULTIPLE CASINGS[I MULTI-LEVELWELL CASING DIN 91 SOILVAPORPROaE 3HP,3SVPs❑ MUD ROTARY CASINGTHICKNESS N/A TYPE OF CASING: [I STEEL [I PVC ❑ OTHER ❑ SOILBORING Rl PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ®No Boring DO: Casing Die: Casing Depth: ❑ INJECTION(Pk So g ) ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO REUSED: []AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yehtj s NO (Note:MM am Freefall Depth is 30 FtWA US'f" (�Q, K1M1 WEWSOIL BORING IDS ev_aociuo_a95 SV-+28MP-176 GROUT SPECIFICATION/S, V II�ti�(Ll f ' C nO�wA� nA �,/.n'�'ft"�PYJO cV 27M0.127 ^ .N� W+x& AUj--r.—l 'f iL DESTRUCTION WORK TO BE PERFORMED: VVVV��r DESTRUCTION METHOD, (CHECK At T�HA7 APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feel 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 feel below surface if>3 feel COMMENTS: I hereby certify that 1 am authorized to complete this application antl that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Project Manager, Hale &Aldrich, Inc. Signed ,d �— Title/Company Y Print Name Cheyenne Wa Dale 1/14/2020 DEPARTMENT USE ONLY n Application Accepted By: Date Issued: 232 0 2 b Grout Inspection By/Date 20 G Destruction Inspection By/Dates: Facifit /Site Information FA Name ^ I s FA Address Z F�f �� $61 PR# 1 V FA PE WP Reviewed By Work Plan Date / 4 `t bl/ V ❑C-57 57 AuNorizafion for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead nc7'Approv ❑MF COMMENTSIC NDITIONS: , s r,7r�.fr 11"1 ' � 6, �1-'�t �l 4t uS -to Will 7- 7l�1 W C.IIS A.� CA'Ok d e.Irt� �yN�.�s7 r rAw+ bA JCS�r�e d r-t*"r �f 4 WWlI- CdytSi -t. WP TYPE PE SC FEE INFO 1AKT REMITTED CHECK# REcNrD BY DATE 111 WELL PERMIT# O INVOICE# Permit Z 0 V 3(3 $152 x 3 Ie 6 C 31124 Ulf"O D g EH02 E. Hazelton Avenue I Stockton, California 95205I T 209 468-3420 I F 209 464-0�Mo ISgati,onM mR AeMhdtior, EHD 29-01 OB-01-17 I`-i�