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APPLICATION FOR WELLIPUMP PERMIM *SAN JOAOUIN COUNTY PUBLIC HEALTH SE cS 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 (Complets In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAI JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. frontage Rd 110-120tH of NE corner JOBADDRESSMRAPNF Ben'. Holt & Pacific Ave Stockton CITY PARCEL SIZE/APi1Of intersection Settling Dry Cleaning Dafen an s s 1... .. owe r. OWNER'S NAME C/O Donald T. Bradshaw, Levine-Fricke-Recon ADOREse Emeryville, CA 9�i608-1829 PHONE SIO-652-4500 CONTRACTOR ADDRESS LIC# PHONE# SUBCONTRACTOR Weeks Drilling ADDRESSSebastopol, CA LIc,,C57- 71 07-823-31E EL�L 1768PHONE r7 TYPE OF WELUPUMP: ® NEW WELL ❑ REPLACEMENT WELL 61 MONITORING WELL# (2) ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Nm ❑Rw.lr M.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL C (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 22 t0 10-inch DIA.OF CONDUCTOR CASING 18-inch D ❑ DOMESTIC/PRIVATE ®GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING 12-inch D ❑ PUBLICWUNICIPAL 11 DRIVEN DEPTHOFGROUTSEALtO depth Of conductor SPECIFICATION cement-bentonite R 9119 IRRIGATION/AG 11LL OTHER BMW SEAL INSTAEDT�BByY GROUT BRAND NAME 1pqE 0 MONITORING GROUT SEAL PUMPED: 6AYw [IN. CONCRETE PEDESTAL BY DRILLER:W Yo ❑No 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE s PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD BOTAFIV_XKAIR RDTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICI THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCEFOR LL REQUIRED INSPECTIONS AT IMI 44022. COMPLETE DRAWING AT LOWER AREA PROVIDED. Title Site Project Manager D.te 5/29/97 PLOT PLAN[Oren to Bael41 Boos •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. 3. DIMENSIONED OUTUNFS 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. S 1Fome Cleaning Village (y Fortner Finest cs o Cale Cleaners G Oe CMW 10 $°o B . Wit �F @$-A/CPT 4 Mw-s I� J -1 i Chevron lIE A Gas Station MW-3 B (` D MW3 ��Pv�' pttE�1; 'o h Mw� Qp yrwr v Mw-T Mw-1 Exxon Gas Station t MW-B (fortnerly Regal �pw�K" e�F�""� and Wickland) $�pGleTw�. + WS W-4 SMar /I MW-7 W3 EIA( MW-3 MW-10 B Y MW-8 MW-II - + + -bouDs DefineC in t o irsi: tinalConsent Decree Uraer, juagement an?T-R9T7rUIICUU , Court on Jan 1996, Sectio Paragraph GPEPARTMMT USE ONLY ApPllpetlen Aec.Pte,l BY Go,q.141, ( 2- Grow Impaction By Gem Pump Inepmtlon By Dele DWtmtion Impaction Ry Det. AiN o'Lpmment.: 1b, J� ( e ACCOUNTING ONLY: AID# FAC# PE CODER FEE INFO AMOUNT REMITTED CHECK#ICARII RECOVED BY DATE PERNIMSERVICE REQUEST NUMBER INVOICE 1 q�