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t fPQ HV °�- �coeg`,• SAN.+)10AQUIN Environmental Health Department l COUNTY---- Greatness grows her - SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 259 N Wilma Ave (for 2301ndustdal Ave.,Ripon Nestle Site) City/State/Zip Ripon,CA.95366 Phone 209-599-2108 Cross Street Hughes Ln APN 25966065 Property Owner* City of Ripon Phone 209-599-2108 Address 259 Wilma Ave City/State/Zip Ripon,CA,95366 C-57 Contractor GeocentricDdlling,Inc License# 1073146 Phone 916-304-2665 Address 1980 S River Rd.Suite E City/State/Zip West Sacramento,CA,95691 Cons ulta nt/Su b-Contractor Haley and Alddch,Inc. License# Phone 949-55"566 Address 42617th St.suite Too City/State/Zip Oakland,CA,94612 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IN MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 185&270 feet 9 BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 6-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS sch e0 TYPE OF CASING: ❑STEEL OO PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: 6' Casing Dia: 2' Casing Depth: approx.176-265' ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH +Z kL, TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE N PIPE ❑ OTHER ❑O OTHER: a nic GROUT SEAL PUMPED? N Yes ❑No LRqW Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDS M-60C2,M60D GROUT SPECIFICATIONS tremie pla neat cementtbrout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED none ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS [--]HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company APM,Haley&Aldrich ,o Print Name Cameron Paez Date 4/9/26 DEPARTMENT USE ONLY Application Accepted By: L� �L� Date Issued: Grout Inspection By/Dates. On Destruction Inspection By/Dates: ZG Facilit /Site Information FA Name L FA Address p .)� I�< FA# PR# FA PE Z t) WP Reviewed By Work Plan Date 'Z ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver Encr6ii5hment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: 2 �u w•4 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# R�EyCVV''D BY DATE WELL PERMIT# INVOICE# Permit 211©l 3l 5 $172x 23 r ✓✓ G c� G y �ll9l Zoo W Lb�� 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 21 p31D:� 31 Site Mitigation Well Permit Application