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SAN JOAQUIN COUNTY 1711�DNiVIENTAI"1=1EAtTFTI�EP;4R__0ENT�T �....:.: x Y, ,`;y:• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • Telephone;(209) 468-3147 Fax:(209) 468-3433 Web:vwvw.s'gov.org/ehd UNIT IV *err 4R ` WELL & BORING PERMIT APPLICATION R ECVE_ D FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR•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 Dep ��` � 7 Eleven Store#17334 Site Location 4501 N. Pershing Ave Cross Street Rosemarie Lane City/State Stockton CAzip 95207 PPMAMM, Property Owner 7-Eleven, Inc. Address P.O. Box 711 City/State Dallas,TX Zip 75221-071lPhone 972-828-6592 C-67 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond C6c 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 Parry 7-Eleven. Inc. c/o Stantec Address 3017 Kilgore Road,Suite 100 City/State R.C. CA Zip 95670 Phone GIS Coordinates:X Y -17-1,321( 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: Ll 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 D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL O PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS II HOSE ❑PIPE _I]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le.AIrSoaroe.Ozonel❑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 AT 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 F7 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 Title/Company Stantec Consulting Services Inc. Print Name a bie Lichtenberg Date i9y /y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS So( /U , EQ.S ICUr' A0c, WORK PLAN DATED -I A rQu A&I l (v I '�D 1<{ APPLICATION ACCEPTED BY -1• Iv a 4"M DATE ISSUED S-Z'1 y 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 REQUESTp PR# 3 O $125 x S 41-3r)-/C( SR# f 5 2 RO# 3500 PR# 2900 C-57 V WC // WAIVER. C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC;Y EHD 29-01 5/09/12 WELL PERMIT APP