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Qu� •. I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a i LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232SITE MITIGATION L�FO♦R .Q. Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/PhrI q •• ""'N� UNIT IV WELL & BORING PERMIT APPLICATION ICEIVERD FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f'�� ` 3 0 2014 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 7-Eleven Store#19976liflllENTALHI=F►LTFB Site Location 1399 North Main Street - Cross Street Northgate Drive PERSE pp F PropertyCity/State Manteca Zip 95336 'A Z16-931-34 Owner_ Lappi Investment LLC Address 9336 N. Saint Martin DrCity/State Fresno Zi 93720 P 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 ��J / Y "-12(. ��: Permit Coordinator:Debbie Lichtenberger 916-384-0724 debbie.lichtenberger@stantec.com CONSTRUCTION WORK TO BE PERFORMED: Project Manager:Danielle Manning 916-384-0706 danielle.manning@stantec.com ❑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(L AirSnaroe.Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 15#OF WELL(S)TO BE DESTROYED ,RW-2,MW-3,MW-5,MW-5A, ®OVER-BORE DIAMETER OF + INCHES TO DEPTH OF 30 to 51FT WELL IDs:MW-6.MW-8 SP-1/SP-1A.SP-2.SP-3.SG-12.SG-13.SG-14.SG-15.SG-16 ®PRESSURE GROUT TO DEPTH�O to 40 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 April 17 2014 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 Regulation n all appl'cabl2 California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenberggr Date pDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS I M(I t(,) S T-f((-<— WORK PLAN DATED ��3 eu t+A 2:c)/4/ APPLICATION ACCEPTED BY j t�n DATE ISSUED AREA GROUT INSPECTION BY r FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ECODE ONLY: AID# FAC# ERO# E RO# INVOICE FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ST PR# $125x l� lPj?� 2250 34(00 / �'Ukrt�rE� OW(��(8� 35a3 3�5 375ss # PR# Z9aa C-57_� WC WAIVER yy 1�' C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOt WELL PERMITLAPP EHD 29-01 5/09/12