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SAN .JOAQUIN Environmental Health Department <br /> ant <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remedlation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 ours Advance Notice Re wired For Ai <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Insist]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 212 East Main Street City/state/zip Ripon CA 95366 phone <br /> Cross Street WA APN <br /> Property Owner' Celia Morel phone 440-264-6425 <br /> Address 212 E Main Street City/statelzip Ripon,CA, 95366 <br /> C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 209599-3706 <br /> Address 3000 Duluth Street City/Statelzip West Sacramento, CA 95691 <br /> ConsultentlSub-Contractor ECM Consultants/Heley&Alddch License# Phone 661-255-2798 <br /> Address 3625 Hyland Avenue City/State/Zip Costa Mesa,CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Ofske BodngsNJells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LIL MONITORING 7� ❑ HOLLOW STEM BORING DEPTH 25.5 feet bg®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapwA4alei) ❑ HAMMERIDRIVEN DIA OF BOREHOLE - 2inch ❑MULTIPLE CASINGS[I MULTI-LEVELWELL CASING OA <br /> [�-B61L�APBR PR@B� �Q MUD ROTARY CASINGTHICKNESS"'—TYPE OF CASING: ❑STEEL E)PVC ❑ OTHER <br /> ❑ SOILSORING ['} PUSH POINT TOP/CPT) CONDUCTORCASING ❑Yas ❑RD Bolig Dix Cashg Da: Casing Depth: <br /> ❑ INJECTION IAt saeaa.Oionel ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBEUSER []AUGERS ❑HOSE ❑PPE <br /> ❑ OTHER ❑ OTHER GROAT SEAL PUMPED? ❑Yes ❑No (Note Ma)dm m Fmdall Depth is 30 R) <br /> WELUSOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLo <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_feet below surface <br /> TREMIE TYPE TO BE USED 0 AUGERS HOSE PIPE [:1 MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that 1 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 %---2 4/V2 Title/Company Program Manager, ECM Consultants <br /> Print Name Binayak Acharya Date July 9,2019 <br /> �/� DEPARTMENT USE ONLY <br /> Application Accepted By: 1"S 60.7 Date Issued: <br /> Grout Inspection By/Dates: - <br /> Destruction Inspection By/Dates: v <br /> Facil" /Site Information / <br /> FA Name /m ` �L FA Address 2 J T(.vldi>� FA# Zr; PR# 45 y <br /> FA PE WP Reviewed By Work Plan Dale <br /> ❑C57 9K,57AaNm¢ationkrOderlo Sg' nPwnt ❑Workers Canp ❑WorIafs Comp Waiver RTKioadwmntPemnt ❑AccessAgreanenl read Agency Approval IffFR <br /> COMMENTS/CONDITIONS: 5&./P W.tt In t C 6� /��let/ �� U.vf Wes' <br /> jVVPTYPrj PE I SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit I Z?0/ 104 s162X (A' /,rL•cc/ � A9.4- 7-0!9 jw/tro3 gzo <br /> 1868 E. Hazelton Avenue I Stodtton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> END 29-01 09a1-17 Site Mitigation Wag Permit Appgration <br />