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SAN JOAQUIN COUNTY `-' OR I G IN v ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •. :P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sonov.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 koco Site Location 2725 Country Club Blvd Cross Street N. Ryde Ave. City/State Stockton Zip 95204 APN 121-210-06 PropeOwner of Stockton, DPW 1465 South Lincoln Street Stockton 95206 209-937-7297 Owner y Address City/State Zip Phone 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 Y__ 2 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 Soarae.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 APPLY 2 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF + INCHES TO DEPTH OF 20 FT WELL IDs:MW-5 and MW-6 ®PRESSURE GROUT TO DEPTH OF '20 FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS ❑ HOSE ®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 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatio nd'II,,a`pplicable California lawns.. Signed �(�/�� cJ7CG7J7�i Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenberger Date mklb DEPARTMENT US�E7 ONLY TOA)SITE MAP IN UNIT IV FILE-SITE ADDRESS /�T C�D�Lq!f�2t1 L� ST K TOA WORK PLAN DATEDwv _1 APPLICATION ACCEPTED BY J• y Kk►a� DATES r`'Ir AREA /G GROUT INSPECTION BY FINAL INSPECTION BY ,DATE 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# '3Fiv $1 mx oo v g3,� 2y� sR# v 337 So 3�0340 (300 PR# 2900 C-57 r/ WC (/ WAIVER____ALQj-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L-,- ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP