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SAN JOAQUIN COUNTY �q`r Creotnesr qrc t4vs here.. Environmental Health Department SITE MITIGATION WELL Ot BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 4555 North Pershing Avenue Cross Street Rosemarie Lane Property Owner* Save Mart Portfolio Owner NLP CA LLC Address 1800 Standiford Avenue City/State/Zip Stockton, CA 95207 APN 110-170-010-000 City/State/Zip Modesto, CA 95350 Phone n/a (vacant) Phone 209-577-1600 C-57 Contractor Cascade Remediation Services License# C-57 1069034 Phone g16-638-1169 Address 3000 Duluth Street City/State/Zip West Sacramento, CA 95691 Consultant/Sub-Contractor SLR International License# Address 110 11th Street City/State/Zip Oakland, CA 94607 Phone 510-451-1761 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ® HAMMER/DRIVEN DIA, OF BOREHOLE 2.5 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑x No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes x❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs B-10, B-113 B-12 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: ccHECK ALL THAT APPLY # WELLS TO BE DESTROYED 3 ❑x OVER -BORE DIAMETER of 2.5 inches to depth of 10 feet WELL IDs B-10, B-11, B-12 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑ 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 MMENTS: Work includes 3dual-nested soil vapor probes. Probes are to be emplaced at 5' and 10', separated by bentonite. Well destruction will occur within the week after sampling. 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, Title/Company Staff Geologist, SLR International Print Name Clayton Blackburn Date 3/11 /2021 DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 3/23/2021 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilitv/Site Information FA Name 1868 E. Hazelton Avenue I Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 VENETIAN SQUARE FA Address 4555 PACIFIC FA# FA0026288 PR# PR0546382 FA PE 2950 WP Reviewed By JW Work Plan Date 2/19/2021 ❑ C-57 IX C-57 Authorization for Other to Sign Permit 0 Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: Submit report/results of finding to EHD per SJC Well Standards provides only 1 hour of inspection time including drive time; any 13.7.2. Please be aware this permit time over 1 hour will be billed to the WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905 1 313 $152x 1 152 CC JW 3/11/2021 Wp0041847 www.sjcehd.com EHD29-01 08-01-17 Confirmation # 121959172 SR0083445 Site Mitigation Well Permit Application