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NECEIVED SAN JOAQUIN COUNTY >. AUG 0 2 2011 2` 2` ENVIRONMENTAL HEALTH DEPARTMENT •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 ``N NN'�� -. •.•:P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.smcehd.com GiKpR 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 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 (209) 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 IN HOLLOW STEM BORING DEPTH 60-80 ft. ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS sC . 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 50-70 ft. TREMIE TYPE TO BE USED: I81 AUGERS ❑HOSE ❑PIPE ® OTHER 6 ❑ OTHER: GROUT SEAL PUMPED? El Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs AS2 through AS7 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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company-&A r,4 I/k y- ATL -,yn un G (%)v Cd� Print Name hL Date T`� � J DEPARTMENT USE ONLY Application Accepted By: Dat sue t , i , Grout Inspection By/Dates: f _ r Destruction Inspection By/Dates: , Facilit /Site Information (L FA Name "r � I �J FA Address �A�-� FA# PR# VV �. N I��L�l _� � 'Lll'�( FA PE aoA Ws- WP Reviewed By _�/ Work Plan Date orkers Comp [IWorker's Comp Waiver 0 Encroachment Permit El Agreement Lead Agency Approval FR 4 Gr57 El C-57 Authorization for Other to Sign Permit COMMENTS/CONDITIONS:C.,,kl C4Q6 SS ��c v.rS �.s�Urw�ct-i ✓ �,v�7� .,�5(,.��c C, W c J�V SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit }—�t'i 1 313 slih .r 69059`1 L y I i I-L-i 11-1 vJ 3 t OB�I.o3� EHD 29-01 10-26-2015 Site Mitigation Well Permit Application