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PQM/" SAN JOAQUIN COUNTY LOP E"ONMENTAL HEALTH DEPARTf�2NT x SITE MITIGATION Mal 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.slgov.orq/ehd �rPOR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMI 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 mad*"gaP('j)vith San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department_ Site Location 1399 North Main St. Cross Street Northgate Drive city Manteca Zip 9533 P, GMIEt303L, . Power 7-Eleven, Inc. Address P.O. Box 711 city Dallas Zip 75221 PC hone�Sc RVIES C-57 Contractor WDC Exploration&Well Address 9580 County Road 93B city Zamora Lic 283326 Phone (530)662-2829 Consultant/Sub Cntr Stante ConsuningCorp. Address 3017 Kilgore Road, Suite 100 City Rancho Cordova Lic Phone (916) 861-0400 Billable Party Stantec Consulting Corp. Address 3017 Kilgore Road, Suite 100 City Rancho Cordova Zip 95670 Phone (916) 861-0400 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: F1 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) I,�';,I M SOIL BORING IDs sG-12 sG-13. sG-14. SG-1 5. sG-16 t J U ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL 91 PVC ❑ OTHER 599 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 2 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 Sparge.Ozone)®HAND AUGER GROUT SPECIFICATIONS Bentonite _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 ® 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) #OF WELL(S)TO BE DESTROYED [_1 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: [:1 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:F]AUGERS E]HOSE [_1PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation and all applicable California laws. Signed - Title/Company Associate Scientist/Stantec Consultinq Corp. Print Name Danielle Manning Date L1 // ZO// DEPARTMENT USE ONLY t SITE MAP IN UNIT IV FILE-SITE ADDRESS I 1 '39q © r� Y l'i I Q 1 n �S+reef- M J t1 T f C A WORK PLAN DATED - D ('_C ell )-nr j e-^rh&3 Z O 1 0 APPLICATION ACCEPTED BY V i C T-o i G e, Ca( fn e DATEf I/SSUED 4 -3�1 �111 AREA 14 GROUT INSPECTION BY V I ctorl e, Cr > rn , FINAL INSPECTION BY Vi`� Y'l,- DATE S j-11 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: _E 1 tS , -1Z s G- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST I PR# 350 $lzzx S Odp 281 9i SSR# DOC, 232 3 S-0 3 C� '�' . d a Roo GAS` 10 PR# -t q '1�. bD 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC s= Pn 9o_ni n7/7R;ln UACI I PFPAAIT APP