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S A N J O A U I N Environmental Health Department <br /> c o u r4 4v -- MAR 2 0 2020 <br /> e�iTtonN`�/ I.ere. <br /> ENVIRONMENTAL HEALTH <br /> SITE MITIGATION W90AAMM 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 All 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 County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 2327 EAST MARIPOSA ROAD City/State/zip STOCKTON. CA 95205 Phone N/A <br /> cross street MARIPOSA ROAD& FLEMONS AVENUE APN 171 290-16 <br /> Property owner' CARL O. SCHATZ REVOCABLE TRUST(ATTN: JANICE FITZGERALD,TRUSTEE) Phone (209)986-1718 <br /> Address 3157 WAGNER HEIGHTS ROAD citylstate/zip STOCKTON, CA 95209 <br /> C-57Contractor ENVIRONMENTAL CONTROLASSOCIATES, INC. License# 695970 Phone (831)662-8178 <br /> Address 3011 TWIN PALMS DRIVE city/staterzip APTOS, CA95003 <br /> Consultant/Sub-Contractor SCHUTZE&-ASSOCIATES, INC. License# Phone (510) 226-9944 <br /> Address 44358 SOUTH GRIMMER BOULEVARD city/state/zip FREMONT, CA 94538 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 60' ❑BOLTEDTRAFRC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapowWater) ❑ HAMMERNRIVEN DIA OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULT14-EVEL WELLCASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS 0.1" TYPEOF CASING: []STEEL❑PVC)[OTHER ACETATE <br /> SOIL BORING 6 )[ PUSH POINT(SPY CPT) CONDUCTORCASING ❑Yes No Boring NO:- cast W. Casing Depth: <br /> ❑ INJECTION Ut ,w.ozanal ❑ HANDAUGER - GROUT SEAL DEPTH TREMIE TYPE TO BE USER. []AUGERS jr HOSE PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? KYes❑ND (Note:Mader m Frosted Depth is 30 Ft) <br /> WELUSCILBORINGIDs B-1 B-2,B-3,B-4,B-5,B-6 GROUTSPEGRCATIoNS NEATCEMENT PORTLAND I/II <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED N/A . ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSE ❑PIPE USHROOM CAP ❑3 f l slow surface or feel bell"surises IT>3 feet <br /> COMMENTS: aJp �f �01.0 Sr f 1, S 2 '�/ R— '�'� <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San�I7Jo/ �aJquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �A O IYJC/ Mi Title/Company CONSULTANT GEOLOGIST/SCHUTZE&ASSOC., INC <br /> . <br /> Print Name JAN SCHUTZE Date 03/18/2020 <br /> ARTMENT USE ONLY <br /> Application Accepted By: Date Issued: 7 <br /> Grout Inspection By/Dates; <br /> Destruction Inspection By/Dates, VV <br /> Facil I ite Information <br /> FAName FA Address �� ' Q FA# eD -9 6q PR# 05Y5W <br /> FA PE 2 - WP Reviewed By Work Plan Dale d3ID <br /> ❑G57 57 AUI1Wza5Dn far Other Io Sign PeanlT ❑Workers CoMp [IWorkers Cane Waiver ❑EnaoacMlleat Permit ❑Aocase Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTsI ONDITIONS: Su O e F_Rb Wj "r% �— S 'Q�e, <br /> a L ok Mi,. AV;IIOt i ALim ( ! "s lgac -k <br /> WP TYPE PE I SC I FEE INFO AMT REMITT D CHEC # RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2 O 31 $152X y"S �Z 3 ?j W Do <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 WWW.Sjce rConn <br /> EHD2MI 08-01-17 ��D'�( ,&do oM�gasm Well Permit APPlkeam <br />