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I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sian Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Print Namet Amanda Ma 4e42,11on behalf of 7-Eleven, Inc. <br /> Title/Company Senior Geologist, Stantec Signed <br />Date 10/4 /18 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: 16 / ti 1 <br />DEPARTMENT USE ONLY <br />SAN JOAQUIN Environmental Health Department <br />COUNTY---- RECEIVED <br />RECEIVED - <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION _A .1 OCT 15 8 <br />ENVIIIUNmE T HEALTH For Wells and Borings Used for Contaminant Investigations and RemediaticaviRcerawmate\LTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEPARTMENT <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 4627 Da Vinci Drive <br />Cross Street March Lane <br />Property owner. Howard Sweet, c/o 7-Eleven, Inc. <br />Address PO Box 711 <br />C-57 contractor Cascade Drilling, Inc <br />Address 120 S 23rd St <br />Consultant/Sub-Contractor Stantec Consultant Services Inc <br />City/State/Zip Stockton, CA 95207 <br />APN 110-02-003 <br />City/State/Zip Dallas, TX 75221 <br />License# <br /> <br />19 ItO <br />Richmond CA 94804 <br />Phone <br />Phone <br />Phone 707-639-7709 <br />Phone 916-669-5982 <br />City/State/Zip <br />License# <br />Address 555 Capitol Mall Suite 650 <br />City/State/Zip Sacramento, CA 95814 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING <br />El MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />M SOIL BORING <br />INJECTION (Air Spann Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs B-1 <br />NUMBER INSTALLATION TYPE <br /> o HOLLOW STEM <br /> MI HAMMER/DRIVEN <br /> El MUD ROTARY <br />2 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br /> 0 OTHER: <br />and B-2 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 20 feet <br />DIA. OF BOREHOLE 2 inches <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL El PVC El OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED J AUGERS HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />FA Name 7., ti ,.„,,, 5).u.,,,_ *.i„432..... FA Address 4 ivil t) cs ,r,,v,,, .1) rota., FA# 00 .2_41 0 -.-1 PR# 0s----j Fo1/41 <br />FA PE 2-k5) WP Reviewed By <br />i— -)( <br />Work Plan Date 10 i 41 / 8/ <br />El C-57 N't-57 Authorization for Other to Sign Permite‘rkers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 1121"6R <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit Z51,0S- , $152x 2 _-i' Set-i rOvtic ,-)')s i---)C 1o414 '‘,1 /41f0,93.icri t.4 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 -le • Site Mitigation Well Permit Application <br />2_51 S13 4. 3 Ur' C(311'0441 i'qr Ce-vo-wi