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� f � �o�a ..�o� ' SAN JOAQUIN COUNTY `_-` ORIGINAI-- a `.` ENVIRONMENTAL HEALTH DEPARTMENT LOP •� `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV •.- :p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /ehd 'ft/Foyia 2 WELL & BORING PERMIT APPLICATION o L�CENED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR,8 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 DepEftftNMENTALHMM 7-Eleven Store#17334 Site Location 4501 N. Pershing Ave Cross Street Rosemarie Lane City/State Stockton CAZip 95207 P � Property Owner 7-Eleven, Inc. Address P.O. Box 711 City/State Dallas, TX Zip 75221-0711Phone 972-828-6592 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 37-9 Y ^12l.321 f 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: CHEc AL HAT APPLY 5 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF S TO DEPTH OF 17 t0 41FT WELL IDs: MW-2.MW-3.MW-5A/MW-5B.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:®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 n all applicable California laws. Signed �' 1'0_ Title/Company Stantec Consulting Services Inc. Print Name Debbie LichtenbergW Date 47Y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5'01 IU , EP.S/NG /,!Lx'. WORK PLAN DATED A W APPLICATION ACCEPTED BY .I. / DATEnI �,_ �V f - i t� EPS �lP GROUT INSPECTION BY 1�/t- C(�l urY1 FINAL INSPECTION BY ��✓•�' ATE ld 1f DESTRUCTION INSPECTION BY- tt ✓— DATE "i?o-1 i COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3 Sn $125. S loo28 70 dQLtrVTzR' g4-3v-<<( SR# gSCP'Z 3�v 3 375 s o0 PR# 2900 C-57 // WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP