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�,su!Ir• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.org/ehd 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-7-0even, 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 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 Permit Coordinator:Debbie Lichtenberger 916-384-0724 debbie.lichtenbergerQstantec.com Project Manager:Danielle Manning 916-384-0706 danielle.manning@stantec.com CONSTRUCTION WORK TO 13E 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 Soatoe.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: T A APPLY #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 15 to 10 INCHES TO DEPTH OF 15 FT WELL IDs: MW-1.MW-2.MW-3.MW4R.MW-5.MW-6.MW-7.SPV1-.SPV-2 ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:EI AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT t`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. Signed7T �� l TitlelCompany Stantec Consulting Services nc. Print Name ueD%ie L i htenbergeP Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS CtI67-1 I rlC 1 WORK PLAN DATED APPLICATION ACCEPTED BY \ DATE ISSUED AREA 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# �5b Z $125 x b5 � SR#0004 .2 101.1 b 37 ')? s oo O d I PR# C-57 WC WAIVER C-57 LETTERKNYALITHO141ZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5109/12 WELL PERMIT APP