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S A N.s10 A Q U I N Environmental Health Department COUNTY Greatness grows here. SITE MITIGATION WELL & 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 25775 South Patterson Pass Road City/State/Zip Tracy, CA 95377 Phone Cross Street 1-580 APN 209-100-040-000 Property Owner* ARP Minimart Corporation (Harshad Patel and Gira Patel) Phone Address 25775 South Patterson Pass Road City/State/Zip Tracy, CA 95377 C-57 Contractor Gregg Drilling and Testing License# C57 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor Arcadis License# Phone 916-865-3171 Address 101 Creekside Ridge Court, Suite 200 City/State/Zip Roseville, CA 95678 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 to 70 ft bgS❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER [g] SOIL BORING 7 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑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? [IYes [INo (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B-49, B-50, B-53 4, B-55, GROUT SPECIFICATIONS Neat cement from bottom of boring to 6 inches below ground surface. R-56 R-57 Asphalt patch from 6 inches below ground surface to surface. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑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: Borings B-49, B-50, and B-53 advance to approximately 70 feet bgs. Borings B-54, B-55, and B-56 advance to 10 ft. bgs. Borings B-57 advanced to 13 ft. bgs. 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 Associate Project Manager Print Name Sherrie Lang Date May 24, 2018 DEPARTMENT USE ONLY ) v Application Accepted By: Date Issued: J-r— Grout LGrout Inspection By/Dates: Destruction Inspection By/Dates: l2 Facilit /Site Information IrvFA Name s i "�,. 1,L4 FA Address L5 11 s r # F E�S�• FA# C, �-,. L j • PR# j�4 34 67 t.p1�.c' Pn.as FA PE ,�.�} j WP Reviewed By L x Work Plan Date 5- I_l t -1 ❑C-57 B C-57 Authorization for Other to Sign Permitork&sComp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ead Agency Approval 09OR COMMENTS/CONDITIONS: J �o c-t�y s h�(,'� !�er't -.�e, ,.,,,� ►.i h �{-p..,. i' t t.�e. 1v •^^�� -v ,vZ s liA41 sz etP&ZArt, c'-p-U.A-r I c�' WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV DBY DATE WELL PERMIT# INVOICE# Permit 1Jq i'} ,t a;� $152 x - v�'f I o -`, �� l 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application Si3 t61X 3