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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP Q' a •` 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.silaov.ora/ehl 1IhlIT lY q�/kpit _._ . WELL & BORING PERMIT APPLICATION - FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION f,N 6 2013 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 rl'ridin ccn}Ip�iarlcs�"a(ritf+!Sfit Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmerfUEE ;,y;ITj4_ VICES Site Location 2725 Country Club Lane Cross Street N.Ryde Avenue City/State Stockton,C Zip 95204 APN 121-210-06 Property Owner. 7-Eleven,Inc. Address P.O.Box 711 City/State Dallas,TX Zip 75221 Phone 972-828-6592 C-57 Contractor National Exp,Wells&Pun Address 1961 Meeker Avenue,Richmond City/State CA Lic 94804 Phone 510-236-6282 Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State R.C.,CA Lic 952595 Phone Billable Party 7-Eleven Inc,Go Stantec Address Rancho Cordova,CA 95670 City/State R.C.,CA Zip 95670 Phone GIS Coordinates:X Y Stantec Permit Coordinator: Debbie Lichtenberger 916-384-0724 Stantec Field Coordinator:Amanda Magee 916-3840743 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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: D STRUCTION METHOD: CHECK AjSL THAT APPLY �+ r 1 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF INCHES TO DEPTH OFI-F5 FT WELL IDs: MW-2 PRESSURE GROUT TO DEPTH OF 13'to 25' FT BELOW SURFACE GROUT SPECIFICATIONS R EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:ElAUGERS ZI HOSE ❑PIPE ElMUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS MW-2 is in the center of the tank pit where two USTs are to be removed. 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 Regulatomd all ap Ucable California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name bbie Lichtenberger for Stantec Date Ole/ 5/ DEPARTMENT USE ONLY e a SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTE BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BYDATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECCK"## RECV'D BY DATE REQUEST P�Rp# Oct $125, /��0C-) /w�-�i 6 SR# � ✓CJ (3500) PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS WELL PERMIT APP EHD 29-01 5/09/12