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SAPS MOWN Einvi6°onmenW Health Department <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 /> 48 Hours Advance Notice R��quired For A(f <br /> Applicallon 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 Fifth Street City/StatelZip Ripon CA 95366 Phone <br /> Cross Street N/A APN <br /> Property Owner* City of Ripon Phone (209599-2108 <br /> Address 269 N Wilma Avenue City/StatelZip Ripon,CA 95366 <br /> C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street City/State/Zip West Sacramento,CA 95691 <br /> ConsultanV$ub-Contractor ECM ConsullantsMaley&Aldrich License# Phone 661-255-2798 <br /> Address 3525 Hyland Avenue Clty/StatelZip Costa Mesa.CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 45 set gs ❑BOLTED TRAFFIC BOX ❑SrOVE PIPE <br /> ❑ EXTRACTION(VaporN7ala) ❑ HAMMERIDRIVEN DIA OF BOREHOLE .9 inrh ❑MULTIPLE CASINGS MULA-LEVEL WELLMING DIA <br /> SOILVAPORPROBE� MUD ROTARY CASINGTHICKNESS m�—TYPEOFCASINQ ❑STEEL ❑PVC ❑ OTHER SOILBORING —� PUSH POINT(GP`CPT) CONOUCTORCASING ❑Yes ❑No Boring DID: Casing Olio Caft Depth: <br /> ❑ INJECTION IAFeaaca Garet ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPEO! ❑Yes ❑No (Nee:Maximum Freefall Depth's 30 R) <br /> WEW SOIL BORING IDS GROUTSPEGFlCATIONS <br /> 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 feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feel belay surface <br /> THEME TYPE TO BE USED AUGERS [I HOSE El PIPE 0 MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> 1 hereby certify that I 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 IJ-n2 4fTr� __ -Title/Company Program Manager, ECM Consultants <br /> Print Name BlnayakAcharya Date July 3,2019 <br /> DEPARTMENT USE ONLY /d <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: .. /'r 's <br /> Destruction Inspection By/Dates: <br /> Facillt ISI a Information <br /> FA Name '" A/LJ�I� FAAddress �(� -yj f� FA# j$1,� '„� PR# Oj <br /> FA PE �� ,V WP Reviewed By _ WA Plan Date 07 <br /> ❑Cd7 66C47ft1forizatimfor0thertoNnPermit ❑WMe's0omp ❑rees,comp waiver as Encroachment Pelmii ❑Access Agreement fd'reeau AOencyy AWmai %PFR <br /> COMMENTSICONDITIONS: <br /> JWPTYPEJ PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit �W" )17 $152 X If7.z AO !3 57L -.7 W>bd 7/ <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 Gael-17 she Miggabon Wei Pelmll Application <br />