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o�4yl SAN JOAQUIN COUNTY —Ei�d1ROi�idlfiTAAt�HfAt�"1 -C�E-P7aRfi(t11ET .-� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.siclov.orct/ehd t�FO WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION APR.3 0 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 pNW" OH&�MEALTH Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department E'tll 7-Eleven Store#17334 �I§Aih'TF6►lt of Site Location 4501 N. Pershing Ave Cross Street Rosemarie Lane City/State Stockton CAzip 95207 APN 110-21-009 Property a wne�ator:7-Eleven, nc. ox 1 a as,TX 75221- 1 , /2-828-65� Owner City of Stockton DPW Address 425 N.EI Dorado Street_ _ City/State Stockton C&ip 95202-2317Phone 209-937-8411 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.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(Le.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) __L_#OF WELL(S)TO BE DESTROYED ID OVER-BORE DIAMETER OFI�O DEPTH OF 36 FT WELL IDs: MW-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 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulatiom and all applicable California laws. Signed !illITille/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenberg Date N, 9", / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS yhO/ N E1Z5 ANG UE S?Zv'CTay WORK PLAN DATED J/+1yic VIti9 I(, / Zca 14 APPLICATION ACCEPTED BY ,1 ,` O*-Ktuwl DATE ISSUED_ -Z-11-1 AREA ��Q 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 1 PR# '35C $125x J 2128 76) SR# 69163 2 7 RO# 3 ) r S 3500 PR# 2900 C-57_ WC ✓ WAIVER -C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /' ENCROACHMENT DOC 416 EHD 29-01 5/09/12 WELL PERMIT APP