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SAN JOAQUIN Environmental Health Department <br /> ,- C f.., <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 /> 4g Hours Advance NoVice R"kiired For IA€g <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 /> Job Address Kingery and Seventh Street Clty/StatelZip Ripon CA 95366 Phone <br /> Cross Street NIA <br /> APN <br /> Property Ownee City of Ripon Phone 440-264-6425 <br /> Address 259 North Wilma Avenue City/State/Zip Ripon,CA, 95366 <br /> C-57 Contractor Cascade Drilling Technical Services License# 938110 Phone 209-599-2108 <br /> Address 3000 Duluth Street city/State/Zip West Sacramento,CA 95691 <br /> ConsultentiSub-Contractor ECMConsultants/Haley&Aldrich License# Phone 661-255-2798 <br /> Address 3625 Hyland Avenue city/StatelZip Costa Mesa, CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 25.5 ee log®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapod ter) ❑ HAMMEWDRIVEN DR.OF BOREHOLE ..9 innh ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> L11 SOILVAPORPROBE _T_q MUD ROTARY GASINGTHIGKNESS TYPE OF CASING ❑STEEL [I PVC ❑ OTHER <br /> ❑ SOIL BORING a PUSH POINT(GP/CPT) CQYWCTORCASING ❑Yes ❑No Weil Do: Cft Dia: C834 Depth: <br /> ❑ INJEGTION(ALaerae.omat ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBEUSEO. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maunam Fiedal Depth Is 30 FQ <br /> WELUSOILBORINGIDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYi <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—inches to depth of_feet <br /> WELL IDs ❑PRESSUREGROUT To depth of—feet below surface <br /> GROUT SPECIFICATIONS [:I EXPLOSIVES From_to_feel belowsurfaoe <br /> TREMIE TYPE TO BE USED AUGERS [I HOSE El PIPE [I MUSHROOM CAP ❑3feetbelowsudawor feelbelowsudamil'*feel <br /> COMMENTS: <br /> 1 hereby ceAlfy that I am authorized to complete this appilcalion and that the work will be done in accordance with <br /> ,,rram� San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed /,.{„� -,4: Tiffe/Company Program Manager, ECM Consultants <br /> Print Name ��``00'' Binayya Acha�rye Date July 9, 2019 <br /> DEPARTMENT USE ONL Y <br /> Application Accepted By:_".W� Date issued: <br /> Grout Inspection By/Dates:- �` Ilw' c AIN S-2 S <br /> Destruction Inspection By/Dates: <br /> cllit /SI a Information <br /> FA Name _ FAAddress ?3d � �d,.y/ FA# �zS 3S� PR# d� 9i57 <br /> FA PE WP Reviewed By �' Work Plan Date _/9 <br /> ❑csl C57AutWzaIonfa Othato Sgn Panes p.IWodars Gump ❑WoWsCanp WaIw 63`Fila0a*WtpMN ❑Aa Ageanant afead AWKYAP"al 21AFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC I /FEE INFO JAMTREMirrFD CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit / $152x z 37,$ �`�� �elm- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> END 2U1 e801-17 Site Maigaeon Well P ftAppkatlan <br />