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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION I �'�jFod�•� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.slaov.org/ehd iA WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION APR.3 U 2014 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 ma pq��T/G�gt�[�F��LTM Joaquin County Development Title, Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. I E tlie'St�eEt'ih'TtIIY1t of 7-Eleven Store#17334 Site Location 4501 N. Pershing Ave Cross Street Rosemarie Lane Cit /State Stockton CPzip 95207 APN 110-21-009 Property We I I U wner perator: 7-E I e ve n,-Fnc.-7.-G. B ox 711, Da I I as, TX 75221 -828-7- 69T--- Owner City of Stockton DPW Address 425 N. EI Dorado Street City/State Stockton ClAip 95202-2317Phone 209-937-8411 C-57 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond CAc 953646 Phone 510-236-6282 ConsultanUSub Cntr Stantec Consulting Address 3017 Kilgore Road, Suite 100 City/State R . 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.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 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 0.e.Air Soaroe.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) 1 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF INCHES OF 36 FT WELL IDs: WA-4 ❑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 Regulati and all applicable California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenbergg Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 415-0/ N Ee5 iNG /�llE — $TZ �CToy WORK PLAN DATED J 1+1V&l Z.4> 14 c� APPLICATION ACCEPTED BY J DATE I Lia r /6, GROUT INSPECTION BY FINAL INSPECTION BY Ukzai W'q 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# 3 5`�.Z $125x / 44 :28 76of f a,T41-1-50-1q SR# 956 3 3�a3 37S R 00 3500 PR# 2900 C-57 f WC ✓ WAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !— ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT PP