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S A N J O A Q U I N 'Environmental 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. Required For Alif <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 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address 212 E Main Street Clty/3tatelZip Ripon CA 95366 Phone <br /> Cross Street N/A APN zSC1� 34o"Z <br /> Property Owner* Celia Morel Phone 20M99-3706 <br /> Address 212 E. Main Street City/State/Zip Ripon,CA 95366 <br /> C57 Contractor Cascade Drilling Technical Services License# 938110 Phone 916-368-1169 <br /> Address 3000 Duluth Street CltylState2lp West Sacramento,CA 96691 <br /> Consultant/Sub-Contractor ECMConsultants/Haley&Alddch License# Phone 661-255-2798 <br /> Address 3525 Hyland Avenue City/State/Zip Costa Mesa, CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BodngsAMells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 45 feet gs ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vap /Water) ❑ HAMMER/DRIVEN DIA OF BOREHOLE �V17�❑MULTIPLE CASINGS[IMULTI-LEVEL WELLCASING DIA <br /> SOILVAPORPROBE MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL ❑PVC El OTHER <br /> SOIL BORING �� PUSH POINT(GPICPTI CONDUCTORCASING ❑Yes ❑No Bering Die: Casig Dia: Casing Depth: <br /> ❑ INJECTION Lao-so+w oroml ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mabum Freefat Depth is 30 FB <br /> WELUSOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APEM <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_Inches to depth of_feel <br /> WELL IDs ❑PRESSURE GROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP Q 3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> 1 hereby ceT1Hy that I am authorized to complete this application and that the work wig be done in accordance with <br /> 1 �-, AS�anAJ,oaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> PSigned l _fl tom'- / TRIe/Company Program Manager, ECM Consultants <br /> Print Name Binayak Ache rya Date July 9,2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: "' "' .Date Issued: <br /> Grout Inspection By/Dates, V.IrA <br /> Destruction Inspection By/Dates: <br /> Faeill /Site Information <br /> FA Name Y .1.k FA Address �3U Z,.,�� -. ,t FA# �p 2S-5Ss PR# �S 7 <br /> FA PE �4&O 1 <br /> WP Reviewed By Work Plan Date !� <br /> ❑C67 C57Aflho&ationfa0/herb Sign Perm1t &1orke/s Comp ❑WoWsCompWaver fd emachment Permit ❑AmessAgreement M'l)WAaencyApprmal O'MFR <br /> COMMENTS/CONDITIONS: /..,i <br /> VIP TYPE PE I SC I FEE INFO JAMT REMITTED1 CHECK# I REc%rD BY I DATE I WELL PERMIT# INvoICE# <br /> _d <br /> Permit z1{rA� ;13 $152x I Ln.•do )'/SZa• AOL 2-1&-ry I 191 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 wvvw.sjcehd.com <br /> EHD 294i 08-0117 She MNgagon Wei Permit Apppcawn <br />