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SANJOAQUIN p <br /> Environmental Health Department <br /> —COUNTY <br /> v <br /> r-onN`P' 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 with San Joaquin Coin Dev�elloopTeennl��jfile, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address Various-seeaeached Maps 23o S-1p�"y ' CltylState/Zip RiponlCe ifoman)5366 Phone <br /> Cross Street APN <br /> Property Owner* Cltyof Ripon Phone (209)5w-2109 <br /> Address 259 N.Wgma Avenue City/StptelZlp Rlpon,CA95366 <br /> C-57 Contractor cascade Environmental Drilling License# 1058336 Phone (916) 638-1169 <br /> Address 300013ululh Street City/State/Zip west Sacramento,CA95691 <br /> Consultant/Sub-Contractor Haley&Aldrich,Inc License# Phone 5109794544 <br /> Address 42617th street Suite lgo City/State/Zip 0alaandraliromiW94612 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BodngsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EIRRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH P0114T(GPI CPT) CONWCTORCASING ❑Yes [I No Boring Dia: Cnlrg Dla: Casing Depth: <br /> ❑ INJECTION(Ateoaae.Ormel ❑ RANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fl) <br /> WELUSOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 23 SOIL VAPOR PROBES ®OVER-BORE DIAMETER of 6 inches to depth of 3 feet <br /> ore <br /> WELL IDS See attached FtgforaVPIoe ®PRESSUREGROUT Todepthof 25 feet below surface "W Sae (a*M.A, <br /> GROUT SPECIFICATIONSNeatceneent Grout [I EXPLOSIVES From to feet below surface <br /> THEME TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I 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 PV 1.r. KIMA Title/Company Regional Manager/Cascade Drilling <br /> Print Name Dustin King Date 111812023 <br /> DE RTM N SE ONLY O^ <br /> Application Accepted By: Dale Issued: L <br /> Grout Inspection By/Datesll& AKUIZM I. �. IZ q1t <br /> If <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information ' I <br /> FA Name e 1 r FA Addressa3Q s FA# PR# �3,0 <br /> FA PE VIP Reviewed By I -,-J—`✓V Work Plan Date <br /> C57 0G-57Authodzabon for Other to Sign Permit ❑Workers Comp ❑WodeersComp Wa ❑Encroachment Permit ❑AccessAgreemenl 9tLeadA9.encyApproyai VkFR <br /> COMMENTS/CONDITIONS: D � Q S S t IEo V r (n( V <br /> d- Rldf; c � -eMq j° ►�°��t�e��p � I / tq/zo C IlYL <br /> WP TYPE I PE SC FE liii; JAMT REMITTED CHECK# RECV'D BY TE WELS PPE�RMIT# INVOICE# <br /> Permit a� $ • X Lt 3p Z- r V '2 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-34 0 1 F 209 464-0138 ww jUh .corn <br /> EH02941104-20-23 rC 66410 <br /> 1 <br /> 2 Site Milgalton Well Pemul Applicetion <br />