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•o�°UrN�; <br /> $AN �JOAQUIN Environmental Health De IZI tment <br /> CEI arCEI <br /> —COUNTY— VED <br /> Greatness grows here. JUL Z s PO�9 <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and RemelidwImONNIENTAL HEAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DE PA VENT ENT <br /> 48 Hours Advance Notice Required For All Inspections <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 /> Job Address 301 N Acacia Ave City/State/Zip Ripon/CA/95366 Phone 209-599A287 <br /> Cross Street Pine Street APN 259-04-005 <br /> Phone 209-599-2131 <br /> Property Owner' Ripon Unified School District <br /> Address 304 N Acacia Ave CltylStatelZlp Ripon/CA/95366 <br /> C-57 Contractor ConeTec Inc. License# 1049248 Phone 510-357-3677 <br /> Address 820 Aladdin Avenue City/State/Zip San Leandro/California/94577 <br /> Consultant/Sub-Contractor Haley&Aldrich Inc License# Phone 51OA95-5105 <br /> Address 1956 Webster Street, Suite 300 CitylStatelZip Oakland/CA/94612 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: 011site Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 190 feel lots ❑MULTIPLE ASINGSX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMater) ❑ 14AMMERIDRNEN DIA.OF BOREHOLE 2 inch [I MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS NIA TYPEOFCASING: [I STEEL [I PVC ❑ OTHER <br /> El SOILBORING 1 MT.1 HP [XIPUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Bang Dia: Casing Dla: Casing Depth: <br /> ❑ INJECTION MkSnxrm O<diel ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPE TO BE USED: ❑AUGERS [I HOSE ®PIPE <br /> ❑ OTHER [I OTHER. GROUT SEAL PUMPED? El Yes ❑No (Note:Maximum Freefall Depth is 30 Fit <br /> WELL/SOIL BORING IDs CPT-120MP-120 GROUT SPECIFICATIONS <br /> 1 investigation location with up to 1 CPT and up to 5 hydropunch samples DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feel <br /> WELL IDS —[I PRESSURE GROUT To depth of_feelbelow surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO B USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHRO M CAP ❑3 feet below surface or feet below surface if>3 feel <br /> COMMENT$'rf fjorrh5s M�IJ'� y `y 'rr.�M►11i� 'PIp.0-- w A-k <br /> (J • I hereby certify that 1 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 /> Signed f� /JiJA'Iuw Title/Company Protect Manager-Haley&Aldrich Inc <br /> Print Name Cheyenne Waldman Date July 26,2019 <br /> EPARTMENT USE ONLY 9 / ^ /GnO �� <br /> Application Accepted By: Dal Issued: G <br /> Grout Inspection BylDates: <br /> Destruction Inspection By/Dates:: <br /> .v r <br /> Facilit /Site Information I. <br /> FA Name /( /lAl s FA Address Z� lrj t�fs','I r FA# ©D 0-5 PR# O �/-//��" <br /> FA PE 'v / O WI?Reviewed By /li Wok Plan Dale 141,t (v If <br /> ❑G57 C-57 Au0wdzalion for Other lo Sgn Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSI ONDITIONS: S•�OM;i /2py+ 1I SHY wti/t al&ys e re. <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# R: U�Y � %ATE WELLM I RM�IT� INVOICE# <br /> Permit qos 3 $152x G. 3 4 rC ' 2 I q W <br /> 1868 E. Hazelton Avenue i Stockton, California 952061 T 209 468-3420 1 F 209 464-011M18 a1 .War sicehd..com <br /> sitEHD 29-01 09-01-17 <br />