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SAN .IOAQUIN COUNTY ORIGINAL t•.a �X ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siciov.org/ehd �tji=oy+a WELL & BORING PERMIT APPLICATIONr) � 30 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EWRONMENTAL HEMY Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made irp ep o Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. p� � 7-Eleven Store#19976(off-site wells) �i�J Site Location 1399 North Main Street Cross Street Northgate Drive City/State Manteca zip 95336 APN 216-330-34 Property Owner City of Manteca DPW Address 1001 W. Center Street City/State Manteca zip 95337 Phone 209-456-8400 C-57 Contractor National EWP Address 1961 Meeker Avenue City/State Richmond Chic 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 7•dPFj 20 Y —17( 2171L/ 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,GEOPROSE,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 ❑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.AirSoarae.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 S BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: MW-4 MW-4A MW-7 ®PRESSURE GROUT TO DEPTH of �0 t0 53 FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE IKI 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 Regulatiorwirqnd,all applicable California laws. Signed Title/Company Stantec Consulting Services Inc. Print Name Debbie Lichtenbe er Date D5 z9 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 131 -1-1 AL MrslIV S r MC-)NT-6f A4 � WORK PLAN DATED APPLICATION ACCEPTED BY ( :f©t4Kw,,i DATE I mo( ) A EA 14010 GROUT INSPECTION BY FINAL INSPECTION BY TE 4-1y 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 c�ppPR# 3 02 $125 x \: y 3U U Cloc, . -30-1L/ SR# �9U3 r1 RO# -3103 3?s 3500 PR# 2900 C-57 ✓WC ✓ WAIVERC-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _dZ ENCROACHMENT DOC EHD 29-01 5/09/12 �1��1��^ WELL PERMIT APP