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r ia�Jriuini r . SAN JOAQUIN COUNTY 7rentness grotvherr-. Environmental Health Department 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 4555 North Pershing Avenue City/State/Zip Stockton, CA 95207 Cross Street Rosemarie Lane APN Property Owner* Save Mart Portfolio Owner NLP CA LLC Address 1800 Standiford Avenue 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 25' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.75 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes 0 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑x PIPE D OTHER MIHPT 10 ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes x❑ No (Note: Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs MIHPT-1, MIHPT-2, MIHPT-3, MIHPT-4, MIHPT-5, GROUT SPECIFICATIONS Neat cement, grouted to surface. PVC pipe used as tremie. MIHPT-6, MIHPT-7, MIHPT-8, MIHPT-9, MIHPT-10 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED DESTRUCTION METHOD: (CHECK ALL THAT APPLY) WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS [:]HOSE©PIPE ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: MIHPT borings leave an open hole, which will be held open with PVC and later grouted to surface with neat cement when work is completed. 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. Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Title/Company Staff Geologist, SLR International Print Name Clayton Blackburn Date 3/11 /2021 DEPARTMENT USE ONLY JEFFREY WONG Date Issued: 3/23/2021 FA Name 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 VENETIAN SQUARE FA Address 4555 PACIFIC FA# FA0026288 PR# PR0546382 FA PE 2950 WP ReviewedBy 1 L JW Work Plan Date 2/19/2021 ❑ C-57 [X C-57 Authorization for Other to Sign Permit Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: Submit report/results of finding to EHD provides only 2 hours of inspection per 6JU VVellStandards time including drive ease be time; any time over 2 hours aware this perm) will be billed to the WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 2905 1313 1$152 x 2 304 CC I JW 3/11/2021 WP0041846 www.sjcehd.com EHD 29-01 08-01-17 Confirmation # 121959172 SR0083445 Site Mitigation Well Permit Application