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r u -yl •/O��UI��C . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.siaov.ora/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. Site Location 2725 Country Club Lar Cross street N. Ryde Avenue City/State Stockton, Zp 95204 APN 121-210-06 Property Owner 7-Eleven Inc. Address P.O. Box 711 City/State Dallas, T)Zip 75221 Phone 972-828-6592 C-57 Contractor Address "City/State Lic Phone Consultant/Sub Cntr._Stantec _ Address .3017 Kilgore Road,Suite 100 City/State Rancho Cordova Lic Phone 916-861-0400 Billable Party 7-11 c/o Stantec Address .3017 Kilgore Road,Suite 100 City/State Rancho cordova Zip 95670 Phone 916-861-0400 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ®OTHER IDs Excavation to recover gw monitoring MW-4 which was paved over during site restoration after UST removal _ TYPE&#OF WELLBORING 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.AvrSoane Ozone)❑HAND AUGER GROUT SPECIFICATIONS 1❑OTHER:excavation to recover well HER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Recovery of well Daved over NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS Cl HOSE ❑PIPE ❑MUSHROOM CAP AT(>_3 FT) FT BELOW SURFACE COMMENTS 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 Regulations,and all applicable California laws. _ ��.� --• F v'�---may- Tale/Company Project Manager/Stantec Consulting Signed Print Name Danielle Manning Date 07/05/13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS WORK PLAN DATED ,/�F�PI ACCEPTED Y DATE ISSUED7� ��_AREA QRMT INSPECTION BY FINAL INSPECTION BY DATE 3 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED C/H/ECK# RECV'D BY DATE REQUEST PR# INVOICE 125 x SR# RO# �� 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 ALL PERMIT APP