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M APPLICATION FOR WELLIPUMP PERMIM .SAN JOAQUIN COUNTY PUBLIC HEALTH SE ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TApIksts) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. frontage Rd 100'1' pf NE corper JOBADDHESStORAPN# Ben'. Holt & Pacific Ave. CITYStockton PARCEL SIZE/APNP intersection SgPrttling DryY Cleaning Defen ants s 19 owe r 5 OWNER'S NAME C/O Donald T. Bradshaw, Lev ne-Fricke-Recon ADDRESSEmeryvTlle, C, 941608-1829 PHONE;10-652-4500 CONTRACTOR ADDRESS LIC# PHONE# 1900 Howe R SUBCONTRACTOR Gregg Drilling & Testing Inc. ADDRESS Martinez, CA 94553 ucCA485165 PHONE b10-313-580C TYPE OF WELLIPUMP: ® NEW WELL 11REPLACEMENT WELL yyyyL L' MONITORING WELL# ❑ OTHER ❑ INSTALUTION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑Naw❑R.pS, H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL K❑RNOPEN BOTTOM UA.OFWELLEXCAVATION 12-inch DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE L=T GRAVEL PACK/SIZE TYPEOFCASING/STEEL/PVC PVC & steel DIA.OF WELL CASING 4-inch D ❑ PUSLICOAUNICIPAL El DRIVEN DEPTH OF GROUT SEAL 45 ft SPECIFICATIONcement-bentonite R ❑ IRRIGATION/AG ❑OTHER CIRCUIT SEAL INSTALLED BY driller GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED:13 Ys [I No CONCRETE PEDESTAL BYDRILLER:❑Yw [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTON/DRILIING METHOD: MUD ROTARY AIR ROTARY X AUGER_CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL ��BBEE DONEINACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL NOT 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 WOR(FOR WHICH THIS PERMIT le ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 11t,001 401114M123. COMPLETE DRAWING AT LOWER AREA PROVIDED. slor X 9—� �� 'k.a - / Tltl, Site Project Manager Dat. 5/28/97 PLOT PLAN IDrew to Bottle)Scale to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. n. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SW \ \ p� Cleaning Village y \\✓� Former Finest -AO Care Cleaners -ro w MW LO foo II B�il�. MW A/CPT MWS I� d MW Chevron RIE Gas Station MW-3 �A g C. p c MW3 h MW-6 ypco" r ISO" Y MW-7 MW((-I-��I,, Exxon Gas Station Mw-9 \ (forand nerlyWick Regal L� 40� 1 /lM/w and Wickland) S�jc►;,� w4 Slxa, q MW-7 MW-2 NAL MW-3 MW-10 B �V MW-8 MW-II *SDCDs defined in the First Final Consent Decree Qrder JudQement and Referenced to Special Master, filed with the Court on Jarry 8, 1996, Section 1V, Paragraph �EPARWIRITLBE ONLY _�Ty/ (I j1 _ Applicetlen Accepted BY' Das 1 • , f 'G2 Are. Grout Irnpactlon By D.t. Pump Iropoetlon By D.ta De.1T.tlon Irnpeetlen BY Dae CommenH: qZR,� vlPIVD ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED,BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 2q IUL3DOEt