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ORIGINAL 4"'"• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP ::'a`� '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �4•. N:p Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd cUNIT IV fio 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#20632 Site Location 4627 Da Vinci Drive Cross Street March Lane City/State Stockton CAZip 95207 APN 110-02-003 Property Operator-7-Eleven, Inc. P.O. Box 711, Dallas,TX 75221-0711 Owner Howard Sweet Address 7421 Spyglass Drive City/State Modesto CAzip 95356 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 Parry 7-Eleven. Inc. c/o Stantec Address 3017 Kilgore Road, Suite 100 City/State R.C. CA zip 95670 Phone GIS Coordinates:X Y 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 WELUBORING 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 9 #OF WELL(S)TO BE DESTROYED IN OVER-BORE DIAMETER OF O INCHES TO DEPTH OF 15 FT WELL IDs: MW-1.MW-2.MW-3.MW-4R.MW-5.MW-6.MW-7.SPV1-.SPV-? ❑PRESSURE GROUT TO DEPTH OF 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 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 Regulatio nd all applicable California laws. Signed ziw,4 Title/Company Stantec Consulting Services Inc. Print Name Lichtenberg Date 00 y L q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS c467_1 V f YIC 1 ll1Ch✓� WORK PLAN DATED APPLICATION ACCEPTED BY DATE I EA GROUT INSPECTION BY FINAL INSPECTION BY f4kill a 0W00N&TE 1 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# 5,5 t>Z. $125 x 5 bcj q2. S111#6o69iP 7 AV[ 0-1 3500 OO()DID 1 PR# C-57 WC WAIVER C-57- IETTE AUTHO IZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 9Dtic)555 WELL PERMIT APP