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SAN lOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greotness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Welts and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to oonstru, andlor Install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San JoaqumP only WelIWeII Stan <br /> cltylstatelZip Rl onICA/95366 `'� <br /> Job Address Pine Street APN O Ov Phone 209-599-2108 <br /> Cross Street NIA <br /> � <br /> Property Owner' Ci of Ri on citylstatelzip Ripon/CA195366 <br /> -3677 <br /> Address 259 N Wilma Avenue 1049248 Phone 510-357 <br /> License# <br /> C-57 Contractor ConeTec, Inc. citylstatelZip San LeandrolCalifomia/94577 <br /> Phone 510-495— <br /> Address 820 Aladdin Avenue License# <br /> ConsultanVSub-Contractor Hale &Aldrich Inc CitylStatelZip OaklandlCAl94612 <br /> Address J956 Webster Street, Suite 300 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offstte Borings[Weils Require Access Agreements or Encroachment Pemtils <br /> BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> TYPE OF TYPE OFWE NUMBER❑ HOLL_ BORING DEPTHON SPISO f ❑ <br /> ❑ MONITORING ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIAL <br /> ❑ EXTRACTION(vaporMlaler) ❑ HAMMERIORIVEN DIA.OF BOREHOLE 21�TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Casnif Depth: <br /> — <br /> ❑ MUD ROTARY CASINGTHICKNESS�I Casing Dia: <br /> ❑® RCASING ❑ es ®N Die: <br /> SOILVAPORPROBE a _ EMIETYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> � HP ® PUSH POINT(GPICPT) TR <br /> SOIL BORING <br /> ANDAUGER GROUTSEALDEPTH is 30 Fp <br /> ❑ INJECTION(A.s o ) ❑ H GROUT SEALPUMPED7 ®Yes ❑No (Nola:'Ilk"'Freef'U Depth <br /> ❑ OTHER <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELU SOIL BORING IDS C - 1 P-16 -11 P11 <br /> CPT-1181 P-118 <br /> DESTRUCTION METHOD (CHECK ALL THAT APPLY of—feet <br /> 3 investigation local ons with p to 1 CPT at each location and up to 5 hydropunch samples at each locationLCER of <br /> DESTRUCTION WORK TO BE PERFORMED: OVER-BORE feetbelow sudace <br /> #WELLS TO BE DESTROYED ❑PRESSURE GROUT To depth of to—fast below sudace <br /> WELL IDs [I EXPLOSIVES From. feel below sudace if>3 feet <br /> GROUT SPECIFICATIONS ❑MUSHROOM CAP ❑3 feet below surface or 1 / <br /> TREMIE P REUSE ❑AUGERS ❑HOSE ❑PIPE ��� C O Yt' <br /> COMM M-� l MKS S rN,t1s �°'L c1.GS�' e y r <br /> C Ordinance Codes and Standards,and all other applicable California laws. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> Sja�n�Joaquin County TitlelCompany Project Mana er-Hale &Aldrich, Inc. <br /> Signed 1 / v /1, 1 Date Jul 26.2019 <br /> Pdnt Name Cheye the Waldman <br /> PARTMENT USE ONLY <br /> Date Issued: ?S fv <br /> Application Accepted By: ,` p <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: FA# 00 PR# <br /> Facilit (site Information AAddress 230 / ON.Y' '-' .7 �`, <br /> FAName N.e,s •e � Is A Work Plan Dale �� !J' <br /> 2 n WP Reviewed By A at [3MFR <br /> FAPE 'j <br /> ❑G57 G57 Aulhod:alion for Other to Sign PemJl ❑Workers Come ❑Wodcers ComPWaiver ❑Enuoachmenl Permit ❑Access Agree�nl ❑Le 9en% <br /> COMM ENTSICONDITIONS: <br /> FEE INFO AMT REMITTED C(H�E/C�K# RECV'D BY p DATE WELL PERMIT# INVOICE# <br /> WP TYPE PE SC 5 l .1.. �� a 2- 19 14 Po 039 I <br /> Per L105 313 $152x WWW.sicehd.corn <br /> F 209 464-0138 i <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 <br /> Slle Mitigation well Permit Appllcagon <br /> EHD 29-0i ii"I-17 <br />