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,oA„��:• o '�' SAN JOAQUIN COUNTY ORIGINAL X ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �` - N'P Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.s' ov.or a UNIT IV �/ � Foa WELL & BORING PERMIT APPLICATION ,C E� v FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %;A`Y 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 $y Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health MOV9 MENTAL HEALTH 7-Eleven Store#19976 Site Location 1399 North Main Street Cross Street Northgate Drive City/State Manteca Zip 95336 PER SEM!99-34 Property Owner Lappi Investment LLC Address 9336 N. Saint Martin Dr. City/State Fresno Zip 93720 Phone 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 3�P�/�/q —y--/2(l 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 WELLIBORING 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:(CHECK ALL THAT APPLY) 15#OF WELLS)TO BE DESTROYEDI/ -2,MW-3,MW-5,MW-5A, ®OVER-BORE DIAMETER OF + INCHES TO DEPTH OF 30 to 51FT WELL IDs:MW-6 MW-8 SP-1/SP-1A SP-2 SP-3 SG-12,SG-13 SG-14 SG-15,SG-16 ®PRESSURE GROUT To DEPTH OFO t0 40 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 Wells to be destroyed per the attached SJCEHD letter dated April 17 2014 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 Regulation all appl'cabl8 California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenberg Date 05 29 pDEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS MA(jN) S rIZE{—I , /�►�Yu 7C,ep WORK PLAN DATED -�<►3 2u/4 pm 18'a') � z APPLICATION ACCEPTED BY Y�_l(c�II-I DATE � � �y L REA /r�9 GROUT INSPECTION BY FINAL INSPECTION BY DATE 7-1 b � 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'oz $125x I' 1�7� 2250 �/30�0 / Cvcc�vrErt 5-30-/� sR#��`f83� RO# 3S6 3�5 �S 3500 PR# 2900 C-57�_ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP