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SAN JOAQUIN Environmental Health Department —COUNTY— Greatness grows here. 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 7647 Pacific Avenue —City/State/Zip Stockton, CA 95207 Phone (209) 476-8669 Gross street Rivara Road APN 077-480-14 Property Owner* Best California Gas Ltd. Ptp. c/o 7-Eleven Phone (972) 828-7011 Address 1722 Routh St-, Ste- 1000 City/statelzip Dallas, TX 75201 C-57 Contractor Cascade Drilling License# 1058336 Phone 916.638.1169 Address 3000 Duluth Street City/State/Zip West Sacramento. CA 95691 Consultant/Sub-Contractor ATC Group Services LLC dba Atlas Techn License# 1083331 Phone 209 579-2221 Address 1117 Lone Palm Ave., Ste 201 B ( dohs CitylStatelZip Modesto, CA 95351 )F?qz SL9) CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile BoringsAVells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporM'aler) ❑ HAMMERORIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DW ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Arsoerae.Orara) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 23 ®OVER-BORE DIAMETER of 8 inches to depth of 40-80 feet WELL IDs See comments below ❑PRESSURE GROUT To depth of feetbelowsudam GROUT SPECIFICATIONS Portland 1/11 cement ❑EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED ®AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Well ID's, MW-3 MW-4R, MW-5 MW-7 MW-12R, MW-13 MW-14, MW-151 MW-17, MW-19, See i20luded-2iaps a d able EA , SVE-2, SVE-3, As-1 , AS-2, AS-3, AS-4, AS-5, AS-6, AS-7 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 Branch Manager/ATC Group Services LLC Atlas Technical Print Name Jeanne Homsey Date November 10 2022 IQ DEPARTMENT USE ONLY —7 2 Application Accepted By: I A�__ Date Issued: Grout Inspection By/Dal ; 2 Destruction Inspection By/Dates: Facllit /Site Information FA Name t r I Z _ I FA Address r FA# PR# 2( '� FA PE 12q '7 WP Reviewed By Work Plan Date a / z ❑G57, G57AuthodzatIonforothertoSign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement sd Agency Approval R COMMENTS/ NDITIONS: Neff-. (r1 f ff f" fie- Sn �We I 1D J it WP TYPE I P I SC FEE INFO JAMT REMITTED CHECK#fRECV'D §Y I ii D TE WELL PERMIT# INVOICE# Permit Z102 133 $1 X f 1 I Z( I o 0 *10Z 1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 2Q9 464-0138 1 www.sjcehd.com END 29-0104-04-07 /(JYril"r/�'rVLa !f� '` -7 O 6 •� 5 `� Site Mitigation Well Perna Application / L Q'l O IJ 7 /\/