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) SAN JOAQUIN En`Elll'P)t'Imentral Healthy Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remedlation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -,;. — fi:.d..:=:�di:i:: `'s'.�,^v„t.'::t: .;"ti1`:Si"Y-', Fov, Ail `ej'ispPct`irjns 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 9-1116.3,and the San Joaquin County Well Standards. Job Address 519 Slocklon Avenue CitylStatelZlp Ripon CA 95366 Phone Cross Street N/A APN L 59-3 2 - 023' Property Owner* Nestle USA, Inc. Phone 44D-264-6425 Address 5750 Harper Road City/Statelzip Solon,OH 44139 C57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 Address 3000 Duluth Street City/Staterzip West Sacramento,CA 95691 Consullant/Sub-Contractor ECMConsullants/Haley&Aldrich License# Phone 661-255-2798 Address 3526 Hyland Avenue CitylStatelZlp Costa Mesa CA 92626 CONSTRUCTION WORK TO BE PERFORMED: *Note; Offstle BodngslWells Require Access Agreements or Encroachment Permits TYPE OFWELUSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p MOMTOPoNG ❑ HOLLOW STEM BORING DEPTH 45 feet bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapvfWaM ❑ HAMMERJDNIVEN CIA OF BOREHOLE _NtA2 inch ❑MULTIPLECASINGS❑MULTI-LEVELWELLCASINGDIA SOILVAPORPROBE MUD ROTARY CASING TFICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL BORING �- PUSH POINT(GP/CPT) CONDUCTOR CASING [3 Yes [I No Boring Dia: Case Ox. Casing Depth: ❑ INJECTIONrAtsosaozmH ❑ HANDAUGE2 GROUTSFALDEPTH TKMIETYPET08E USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Nola:MW&num Fneefall Depth is 30 FT) WELUSOIL BORING IDS GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:!CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feet WELL IDS []PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES Fran_lo_feet below surface TREMIE TYPE TO REUSED AUGERS ❑HOSE ❑PIPE ❑MUSHROOMCAP ❑3 bet belowsurfamor feet below surface'rf>3 feel COMMENTS: 1 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. Signed 1 Jf'1 Y2 -e)-- _ _ Title/Company Program Manager,ECM Consultants Print Name Bi ayek Acharya Date July 3,2019 DEPARTMENT USE ONLY Application Accepted By: telf- to Issued: r Grout Inspection By/Dates: Destruction Inspection By/Dates: 4 2 0q Facliftyl3ita Information FA Name ram` ArlleG FA Address _/��.i F �O 1,S,�ff P ps 41 FA PE L 9G0 ,v++ WP Reviewed By �+'eA— Work Plan Date ❑C57 RrT-U AutlWadan furOdwrtoSgA Pont 6rwmers Camp ❑Wark&sCarp Waive GrEnnoachmen[Permh ❑AxessAgreemenl Lead PgenSy Appoval Li dFR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#. Permit 9/3 $152 x / /S:+d �o3 97 90 1868 E. Hazelton Avenue I Stockton, California 95205 l T 209 468-3420 i F 202 464-0138 1 wvrw.sjcehd.com EHD 284a Gs-n1-n sna Magalbn WQ P [Appl a6M