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ORIGINAL oea! i . SAN JOAQUIN COUNTY � �:•.�E•.oma ENVIRONMENTAL HEALTH DEPARTMENT LOP . 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION p Telephone: 209 468-3147 Fax: 209) 468-3433 Web:www.sipov.org/ehd UNIT IV 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 Standards of the San Joaquin County Environmental Health Department. 7-Eleven Store#14117 Site Location 2725 Country Club Blvd Cross Street N. Ryde Ave. City/State Stockton Zip 95204 APN 121-210-06 Property Rockville Group Acquisitions 15 Atkinson Road Rockville ter, NY 1157 Owner P Address City/State �� hone C-57 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond CAc 953646 Phone 510-236-6282 Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road, Suite 100 City/State R.C. CA Lic 952595 Phone 916-384-0724 Billable Party 7-Eleven. Inc. c/o Stantec Address 3017 Kilgore Road, Suite 100 City/State R.C. CA Zip 95670 Phone GIS Coordinates:X 37•Cl4��5 Y r2 t'33 G Qg Permit Coordinator:Debbie Lichtenberger 916-384-0724 debbie.lichtenberger@stantec.com Project Manager:Danielle Manning 916-384-0706 danielle.manning@stantec.com CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPY) 10#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF + INCHES TO DEPTH OF 25 to 5OFT WELL IDs:MW-1,MW-3,MW-4 MW-7,MW-8,1-1,1-2,1-3,1-4,1-5 ®PRESSURE GROUT TO DEPTH OF �0 to 35 FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:M AUGERS ❑HOSE El PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS Wells to be destroyed per the attached SJCEHD letter dated July 22, 2014 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatiqp%,ang all applicable California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenber er Date 06142///4/ -) DEPARTMENT USE ONLY 7�y SITE MAP IN UNIT IV FILE-SITE ADDRESS / of t N�TR% SCIS J S 14 0uL WORK PLAN DATED M69 0 zoo y APPLICATION ACCEPTED BY DATE ' REA IG GROUT INSPECTION BY FINAL INSPECTION BY DATE r-OR-/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3 5�2 $130 XV l Qo �3S Z� C r�2 �' y sR# �0 3 scto RO# 3500 PR# 2900 C-57 (L WC A- WAIVER NCS C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r ENCROACHMENT DOC �L EHD 29-01 5/09/12 WELL PERMIT APP