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SAN JOAQUIN Ezntflronmell" I Health € epa tment <br /> . �iClIryBD <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION 1UL 1 <br /> For Wells and Borings Used for Contaminant Investigations and RemediaENVIRUNME OgLH'EgLTH <br /> NON-REF NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEPARTMENT <br /> ON S ik.t?? S;•=.C.?3;i Oil +'^.'. '.2S €,"a:7 Y,tr pr <br /> {v; . o...l."t`:T f'�:ice';:r�•%f;v <br /> Application is hereby made to San Joaquin County for a permit to construc t andlor install the work described. <br /> 15.3,and <br /> This application Is made incompliance with San Joaquin County Development Title,Chapter Ripon CA 95366 the San Joaquin County Well Standards. <br /> Phone <br /> Job Address Alley ways, North of Firs[Street <br /> CltylStateop <br /> Gross Street <br /> NIA APN Phone (20 <br /> ' <br /> Own <br /> 269 N <br /> r• CBy of Ripon Ripon,CA 95366 <br /> Property CitylStatelZip g16-368-1169 <br /> Wilma Avenue <br /> Address License# 938110 Phone <br /> Cascade Drilling Technical Services West Sacramento,CA 95691 <br /> C-57 Contractor CltylState121D 661-255-2798 <br /> Address 3000 Duluth Street Phone <br /> ECM ConsultantslHaley&Aldrich License# <br /> ConsultantiSub-Contractor CllylstatelZip Costa Mesa CA92626 <br /> Address 3525 Hyland Avenue <br /> CONSTRUCTI N WORK TO BE PERFORMED:*Note; Ofisite BoringslWells Require Access Agreements or Encroachment Permits <br /> 25.5 feetbg®BOLTED TRAFFIC BOX STOVE PIPE <br /> TYPETYPE OF, N BER INSTALLATION TYPE CBOR U _TRUN <br /> DEPTH <br /> NSPE IFICAT�OIN ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> MONITORING ❑ HWMERATBA DA.OFBOREHOLE <br /> ❑ EXTRACTION(vapwwaler) ❑ FUUIMEfUDrdVEN CASING THCKNESS� Ty a LNG: ❑STEEL ❑ Dia ❑ OTHER <br /> s�SOLVAPORPROBE CC�� MUD ROTARY Cas§ig Dia: PIPE 0s:Aw: <br /> (© SOIL BORING P} PUSH POINT(GP/CPT) GROUT SEALTOR DEPTHCASIN ❑yea ❑NO �ENPETOBEUSEDEIAUGERS ❑HOSE ❑H <br /> ❑ INJECTION(,, i omrcl _❑ HANDAUGER GROUT SEAL DEPTH <br /> ❑ OTHE(c GROUTSEAL PUMPED? <br /> ❑Yes❑Nb (Note Maxinum FredaA DePlh k30 Fq <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELL!SOILSORING IDs <br /> DE TRUCTION METHOD• (CHECK ALL THAT PL <br /> DESTRUCTION WORK TO BE PERFORMED: ❑OVER-BORE DIAMETER of__rnchestodePthOf_feat <br /> #WELLS TO BE DESTROYED ❑PRESSURE GROUT To depth of—feetbelowsurlace <br /> WELL IDS ❑EXPLOSIVES From—to—leetbdawsudaca <br /> GROUT SPECIFICATIONS MUSHROOM CAP 3 feet below sudaceor Teetbelaw surface it>3 feet <br /> TREMIETYPETOBEUSED ❑AUGERS ❑HOSE ❑PIPE <br /> COMMENTS: <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable CaINOfnia laws. <br /> 1 fiereby cerilfy that 1 am authoraed to complete this application and that thsworkwlll be done In accordance with <br /> TitlefCompany Program Manager, ECM Consultants <br /> Signed_ Date July3.2018 <br /> Binayak Acharya' " <br /> Pdnt Name <br /> ARTMENT USE ONLY <br /> Date Issued: 7/« � y <br /> Application Accepted By: _ �,rti/,, 14� 1 <br /> Grout Inspection By/Dates <br /> Destruction Inspection By/Dates:Facll' FA Address 1Site information ,t FA# PR# Q�y 6CR <br /> Wears f Work U, rk 'te <br /> M , Plan Date <br /> FA PE 6 D WP Reviewed By a MFR <br /> Waver Er¢roarAnanlPenna ❑AecessA9��a°1 Ixad A9acY <br /> ❑C37APIhdiratim ferOherb Sign Pemct oikars Camp ❑WakeVs Camp/�,� �� 1YVv, ' <br /> COM ENTSICONDITON9: / e l P b.L CLIV) <br /> V AMT REMITTED REC'V'O/BV `DATE WELLLPEI IT# INVOICES <br /> WPTYPE PE SC FEE INFO <br /> $152x li <br /> Per mO z9ts� <br /> T 209468-3•1 01 209464-0138 1 VvwW.sjcehcLCom <br /> 1568 E. Hazelton Avenue 1 Stockton, California 95205 I Silo MWgaai WetpeamnAPPi[Caaon <br /> EHD 2ee1 060147 <br />