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SAN ) UAQWN Environmental Health Depar$me; It <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Welts and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4v, . .+liF-'a -I:ivar!Co N:01 08 For Aii "'I feTAicn-t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br /> This application is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3.and the San Joaquin County Well Standards. <br /> Alley ways.North of Main Street Cil IStatelzi Ripon CA 95366 Phone <br /> Job Address Y wa Y Y p <br /> Cross Street N/A APN <br /> Property OwrI City of Ripon Phone (209-699-2108 <br /> Address 259 N Wilma Avenue City/6tatelzip Ripon,CA 95366 <br /> C-57 Contractor <br /> Cascade Drilling Technical Services License# 938110 Phone 916a6&7169 <br /> Address 3000 Duluth Street Cltyl6tate2 West Sacramento,CA 95691 <br /> ip 661-255-2798 <br /> Consultanitsubcontractor ECM ConsURantsIHaley$Alddch License# Phone <br /> Address 3525 Hyland Avenue City/Statelzip Costa Mesa CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: ONsite Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONRORING ❑ HOLLOWSTEM BORING DFJ'TH 45 feel gs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(va"Mater) ❑ HAMMEAAPoVEN DIA OF BOREHOLE nrh ❑MULF CASING. [IS❑MULTIPIC 11 OTHERELL CASING DIA <br /> SOILVAPORPROBE MUD ROTARY CASINGTHICKNESS—'f TYPE OF CASING: [I STEEL ❑INC ❑ OTHER <br /> SOILBORING —� PUSH POINT(GP/CPT) CGNDUCTORCASING ❑Yet ❑No Boring Da. Casrp De: Casing Depth: <br /> ❑ INJECTION Mir S,",0--1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBEUSEO ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yea ❑No (Note:Matenum FIST Depth is 30 Fp <br /> WELL/SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHoo• ICNECIC ALL THArAPPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_indm to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED QAUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP 31aetbelowsudaceor feel below surface if>3 fete <br /> MMENTS: <br /> 1 hereby eeMlty that I am assthortred fo eompiete this appiicadon and that the vomkwill be done In accordance with <br /> Ian Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ^ Al. L 'I TitleTCompany Program Manager,ECM Consultants <br /> Print Name � yak Acharya Date July 3,2019 <br /> _DEPARTMENT USE ONLY <br /> Application Accepted By: AP AI M- 4111A 5I Date Issued: 7-5-�9 <br /> Grout Inspection By/Dates: <br /> Destmclion Inspection By/Dates: 1�^t lr 1�r°'Y�'� 7 tl✓ t 1 l <br /> Fac lit !site Inf rmatiOn <br /> FAName ` f �1Ar6� t Z FA Address �� A FAO �Zs f PR# �, <br /> FA PE WP Reviewed By Work Plan Dale <br /> (/D <br /> ❑C57 AUiher'vagonfaOlhaztaSignPemil scoop ❑WodrNsCaneWaver (sl'fnacachmaltPerml ❑AcceSSAgreanent radAeargAppwai l3ltFR <br /> COMMENTSICON DITIONS: <br /> WP 7YPE PE SC FEE INFO AMT REMITTED CN1 x# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Perme "05� 5152 x 3 4, '11 404/+4 A p 7 f—;j &W-AJd 7Q J <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.corn <br /> EMDYB0109-0f-1) &M Mnigatbn Well PantilApplica n <br />