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APPLICATION FOR WELL/PUMP PER SWOAOUIN COUNTY PUBLIC HEALTH SE ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 / L NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L ,5 7 bU LG (Complete In Triplicate) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WnH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBUC HEALTH BERMES.ENVIRONMENTAL HEALTH DIVISION. JOBAOVMSeroRAPN1376 Lincoln Center CnN Stockton PARCEL BIZF/APNs097-41-46 s 90 SETTLIN D OWNER'S NAME C O Donald T. Bradshaw, Levine-Fricke- econ ADDRESS Emeryvil le, CA 94b08-1827 PHONE�10-652-450 CONTRACTOR ADDRESS LRCM PHONE/ 111 ower ar ace SuBCONTRACTOnTransglobal Emvironmental Geochemistry ADDRESS Rancho Cordova, CA 9574$JC1706568 PHoNE 816-853-8010 TYPE OF WELL"Nip: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Rapalr N.P. DEPTH PUMP BET_". FIRST WATER LEVEL 0 TYPE OF PVMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING VADOT B ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION ePECiFICATIGNS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1-inch DIA.OF CONDUCTOR CASINO ❑�a D ❑ DOMESTIC"VRE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEM/PVC n/a DIA.OF WELL CASINO n/a O ❑ PUBLiCBAUNiC1PAL ❑DRIVEN DEPTH OF GROUT SEAL n/a SPECIFICATIONc ement-bentonite R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY__n a GROUT BRAND NAME n/a E ❑' El MONITORING GROUT SEAL PUMPED: y- ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yr ❑Ne S APPROX.DEPTH mUltinle borings 5-65 ft bgs LOCKING CHESTER BOX/STOVEPIPE S PRGPOeEO CONSTRLICT10NIdnWNG METHOD: MUD ROTARY AIR ROTARV AUGER CABLE OTHERHydT8IiC Push 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE MWORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AMCC,A�NT My[jT CALL 11�NOW,,IN ADVANCE FOR ALL REQUIRED UmMVIONe AT IMq 4011 X21. COMPLETE DRAWING AT LOWER AREA PROVIDED. 61Eroe Xr '/FI /f�.i/ •Y(J /L TRI. Site Project Manager D.ro T %OT PUN IDr.w to BaN.I%-I- le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE EEWAOE DISPOSAL SYSTEM OR PROPOSED 9. Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION SEWAGE DISPOSAL G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OFF WELLS WITHIN RADIUSSOOF F ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. Otj THE PROPERTY OR AD.MININn eo....-•.^• 90 ` `Y % C. o U O Z INr n 'oNri O C •SS E - 01 ° �1 .E. L4 N / .2 l�Ja IY• r, ®�16 10 :SO I Z 4L i O 1 DEPARTMENT USE ONLY APPllesllen A. "tw a, Greta ImpeeBen BY D.b PUnP ImP.etlen BY Dae D.1. Omvwtl.n Imneetbn er cemme,n.: ACCOUNTING ONLY: AIDE FACT PECODEB I'MINFO AMOUNT REMITTED CHECKIMASN RECEIVED BY DAT I'MMITISERVICE REOVEBT NUMBER INVOICE Pub.Health SEN.-Enviro.173(1/97)