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I <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i4c-Cci3 ra£{'; dfred Foy AB frTsmaCV-01 <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 9-1 it 5.3,and the San Joaquin County Well Standards. <br /> Job Address Alley ways,North of First Street City/State2lp <br /> Ripon CA 95368 Phone <br /> Cross Street N/A APN <br /> Property Owner, City of Ripon Phone (209-699-2108 <br /> Address 259 N Wilma Avenue City/State2lp Ripon,CA 95366 <br /> C•57 Contractor <br /> Cascade Drilling Technical Services License# Phone 938110 916-368-1169 <br /> Address 3000 Duluth Street CitylstatelZip West Sacramento,GA 95691 <br /> ECM ConsultantalHaley&Aldrich Phone 661-255-2798 <br /> Consultant/Sub•Contractor License# <br /> Address 3525 Hyland Avenue City/State/Milo Costa Mesa CA 92626 _ <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATIONTYPE CONSTRUCT ION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DE—DEPTH <br /> 45�aet b91 ❑BOL1EDTRAFBC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VepaAYafte) ❑ HAMMERIDfWEN DMA.OF BOREHOLE 2inrh ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA <br /> SOILVAPOR PROBE [, MUD ROTARY CASINGTHICRNESS 14" TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL BORING _� PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑NO Bong OIa: Casing Ira: Came Depth: <br /> [IINJECTIONIAhsorce Onee1 ❑ HAND ANGER GROt1TSEALDEPTH THEMIEIYPETO BE USED. ❑ADGERS ❑HOSE ❑PIPE <br /> [I OTHER ❑ OTHER GROUT SEALPUMpED] ❑Yes ❑No Mate:Madmum Ftedai Depth is 30 FO <br /> WEW SOIL BORING IDS GROUrSPEOHCATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rCHECKALLTHAT APPLM <br /> #WELLS TORE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELLIDs ❑PRESSUREGROUT To depth of_,feetbeiow surlace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES Fran__to_reef below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSE [I PIPE 0 MUSHROOM CAP ❑3 feetbelowsudace or feetleelaysurface9>3 feet <br /> COMMENTS: <br /> liberality ceriNy that 1 am authorized to complete thia apPlicatlon and ihaltheworIL will be done to accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ,. � Title/Company Program Manager,ECM Consultants <br /> Print Name HmayaK Acharya Date July 3,2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: r� /Date Issued: 7- <br /> Grout Inspection By/Dates <br /> Destruction Inspection By/Dates <br /> Faci1N (Site Information <br /> FA Namet <br /> ytlL FAAddmss �O •Y�••Sjr� FA# i� � PRd 1S6a'FA PE WP Reviewed By 9ip._ Work Pip Dale <br /> ❑CzatonfarOW10SgnPwM eevCanp ❑woaarscompwaver oaChMtpMft ❑Aoasspgeament LfeaiA9MAppreal Gt9FR <br /> COMMENTSICONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECKS RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit Zynf jg $152x 3 y;G� .0 P it.,AbIdY7 <br /> 1368 E. Hazeiton Avenue { Stockton, Cahfomia 96205 { T 209 468-3420 j F 209 484-0138 { wwws hcl Com <br /> EHD 2941 oaA1-1] Site MlFgaa Ap cse9n <br /> f�eiob 5 vkeA /I$/�� 5� yob � nsfi�il�� G'�/►s/rq <br /> C 'M - � Way 5yb\gy,� IIoIIa r Glsy,4+I4- <br />