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S_AN JOAQUIN Environmental Health Department <br /> -COUNTY <br /> a r % Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <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 Wth San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 142&206Sou05toddon Avenue City/State/Zip Ri"VC81ifoma'95366 Phone <br /> Cross Street FmAStreet APN <br /> Property Owner* Ripon Fire Department/American Legion Hall#190 Phone (209)5m4209/(206)924-4419 <br /> Address 142&206Soum St.Kw Avenue City/State/Zip Rlpon,CA95366 <br /> C-57 Contractor Cascade Environmental Drilling License# 1058336 Phone (916)638-1169 <br /> Address 3000Demmstreet City/StatelZlp west Saaament0.CA95691 <br /> Consultant/Sub-Contractor Haley&Aldrich,Inc License#, Phone 5108794544 <br /> Address 42517NSheet Sulle700 City/StatelZip DaWend/Caldomlal94612 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapx/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY GASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Bomg Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Alrspxae.or i ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED: [I AUGERS El HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? [I Yes [I No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELD SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) [� <br /> #WELLS TO BE DESTROYED 2 SVPS ®OVER-BORE DIAMETER of 6 inches to depth of C3 feet / (l <br /> WELL IDS sv-13z/sv-123 OPRESSUREGROUT Todepthof 15 feet below surface Coo L6thvltla+� <br /> GROUT SPECIFICATIONS Neat cement Gran ❑EXPLOSIVES From to_feet below surface �18u1 <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> 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 �✓`O't �' v KG' " Title/Company Regional Manager/Cascade Drilling <br /> Print Name Dustin King Date 11.8.23 <br /> DEPART ENT USE ONLY <br /> Application Accepted By: Date Issued: ✓`/� �(— <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faciiit /Site Information <br /> FA Name FAAddress 2 V n FA# 00 Z5 qft PR# 051}1+ � <br /> FA PE 1 2,216 <br /> 0 WP Reviewed By Work Plan Date <br /> 57 ❑G57Authorization for Other to Sign Permit ❑Workers Comp ❑Warkeescomp Wai ❑Encroachment Pelmil ❑AccessAgreemenl Lead AgencyApproval AMFR <br /> COMMENTS/CONDITIONS:�, / / _iro 4l_ . P� 0 C+ RS �C 1 �k,E`ie t,J -�"� Or <br /> Alkc.� -QYvt� t4 re�sf S1�tmse d{n�t�� Ili R'l'20J� Lh/ ivi, 7Vvar;e1.,4A_ ss <br /> cAJAI5 <br /> WP TYPE PE SC I FEE INFO AMT RENUTTED1 CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit Pq0j 313 $t f- ? C-d ;1AkV3D z UJ C)C) ' Z2 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 s)ce <br /> EHD 29-0104-20-23 CC# I-4—Vq S_6 <br /> 403 <br /> 03 Site Mitigation Well Pemtit Appllgtlon <br />