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1 <br /> rIWN <br /> " ', SAN.AA0I11H Environmental Health Department <br /> —COUNTY <br /> 9c,vaa�w' Greatness gr, <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 /> 48 Hours Advance Notice Required For All Inspection:, <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/ziple TOCKTON, CA 95205 Phone N/A <br /> Cross Street MARIPOSA ROAD& FLEMONS AVENUE APN 171-29 16 <br /> Property Owner' CARL O. SCHATZ REVOCABLE TRUST(ATTN:JANICE FITZGERALD,TRUSTEE) Phone (209)986-1718 <br /> Address 3157 WAGNER HEIGHTS ROAD clty/state/zip STOCKTON, CA95209 <br /> C57Contractor ENVIRONMENTAL CONTROL ASSOCIATES, INC. License# 695970 Phone (831)662-8178 l <br /> Address 3011 TWIN PALMS DRIVE city/stateizip APTOS, CA95003 <br /> ConsultanNsub-Contractor SCHUTZE&ASSOCIATES, INC. License# Phone (510)226-9944 <br /> Address 44358 SOUTH GRIMMER BOULEVARD city7state7zip FREMONT, CA 94538 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ORsite Borings/Wells,Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORINGDEPTH 15'and/or 60'0 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VoWM'ater) ❑ HAMMERNWVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL❑PVC X OTHER ACETATE <br /> X SOIL DOPING � PUSH POINT(GPI CAT) CONDUCTORCASING ❑Yes KNo Baring Die: Cashg Die: Casirg DWh: <br /> ❑ INJECTIONrAinsee ormef ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPE TO BE USED. ❑AUGERS❑HOSE XPIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? XYes ONO (Note:MadMnFrcefallWis30Fq <br /> WELU SOIL BORING IDs 13-7,B-8,B-9,B10,B-11,'8 I4- GROUTSPECIFICATIONS NEAT CEMENT(PORTLAND 1/I0 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED N/A ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL We ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP 3 feet below surface or feel 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 In Coun Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company CONSULTANT GEOLOGIST/SCHUTZE&ASSOC., INC. <br /> Print Name JAN SCHUTZE Date to joy2ozo <br /> it ,DEPARTMENT USE ONLY ''/I <br /> Application Accepted By: Date Issued: /0 T 00 2 0 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: I-L - O7)0 <br /> Facilltv/Site Information <br /> FA Name FA Address 23 /Vlq�/ � FA# 00 25 Slog PR# a,4 ,coo 6 <br /> FA PE WP Reviewed By LA Work Plan Date !D s <br /> 0057 C57Au9aiUtknfor Olherb Sign Peenk ❑Workels Camp ❑WakelscornyWawer Erlaoachmem Permit ❑A.aess Admement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/ N TIONS: <br /> WP TYPE PE SC FEE INFO AMT REmn­TEDj CHECK#I RECV'D BY DATE W L PERMIT# INVOICE# <br /> Permit $152 x y / v\ /p I✓V 1 " (, <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 OB-01-17 �Site Mitigation Well P�>�� <br />