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f oPa�l"` c SAN JOAQUIN COUNTY RECEIVED '? ENVIRONMENTAL HEALTH DEPARTMENT N: 1868 Hazelton Avenue, Stockton, CA 95205-6232ICr a 2 201? ��-..,�.•,.•;P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicj*dxgm._ �fFOR`' LHFF�,I,LTH SITE MITIGATION WELL & BORING PERMIT APPLICIA-MU m:<Es For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Cross Street Rivara Road APN 077-480-14 Property Owner' Best California Gas Ltd Ptp. c/o 7-Eleven Phone Address 1722 Routh Street City/State/Zip Dallas, TX 75221 C-57 contractor Gregg Drilling&Testing License# 485165 Phone (925) 313-5800 Address 950 Howe Rd. city/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor ATC Group Services LLC License# Phone (2209) 579-2221 Address 1117 Lone Palm Avenue, Suite 201B City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 ft. ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 1 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 20 ft. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SB2 GROUT SPECIFICATIONS neat cement 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: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Sa Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company ,,,., A'�6rpyp �if-UrciS Print Name Date d 7 DEPARTMENT USE ONLY �Y Application Accepted By: Date Issued: Grout Inspection By/Dates: + 7,17 Destruction Inspection By/Dates: Facilit /Site Information FA Name t F}'I �' ( �' FA Address �tl� Q AUA(. 61ly FA# pp'j,N Y PR# fogy FA PE 13A(0� WP Reviewed By 7 L_)", Work Plan D S �/ �, 1 p C-57 ElC-57 Authorization for Other to Sign Permit Worker's Comp El Workers Comp Waiver ❑Encroachment Permit [Iate Access Agreement Lead Agency Approval ®fv1FR COMMENTS/CONDITIONS: lA,3 k,,i,v V V,2 Okd ^A^Ae. -- 5w w.S fe-t .,per SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# e i7 Permit �`�V �: $1a�_ XVS-'lI L. Y �v1"1�L EHD 29-01 10-26-2015 Site Mitigation Well Permit Application