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PPLICATION FOR WELL/PUMP PERM <br /> , SA AQUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 nn CPI <br /> (209) 468-3420 �y�TQ{vYll} L F1C�1925 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V� _13351o�s+•lOf V EcR'sboAPPLICA ` _L <br /> ICampl&R In Triplknt&) ` I4 y I l5kN Eye VI C�� <br /> JOAQUIN ON IB Y DE EL MADE TO THE SAN JOADVIN COUNTY FOP A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE MIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESSORAPN# 374 Lincoln Center Benjamin J. Holt Dr. app&rox 8801 E of <br /> Settling g CRY Stockton PARC IZVAPNf n,,.k�l„r� Pl. <br /> g ry eanTn a en en 1900 Powell St. 12th Floor <br /> OWNER'S NAME c/o Donald T. Bradshaw Levine-Fricke-ReconADOREee Finaryv;lTo (`A Z4Fn8-1927 p� �452-4500 <br /> CONTRACTOR ADORERS d UC# PHONE# <br /> BURCONTRACTOR XX Greg In-Situ, Inc. AUDIIESSMaortNrneze,RCA 94553ucQA-656407 P1T510- o-FIE'{1� 800 <br /> TYPE OF WELL/POMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ITYPE OF_MMP) <br /> ❑N.0 ReP.lr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# CPI BOIL BORING a <br /> ❑ <br /> DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION&PECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CASINO N/A D <br /> ❑ DOMEBTICA'RIVATE El GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC N/A Olq.Of WELL CASINO N/A <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL Total Depth SPECIFICATION Cement-Bentonite RD <br /> EI <br /> ❑ IRRIOATION/AG EILOTHER GROUT SEAL INSTALLED BY Cnntrartpr OPOVT BRAND NAME N/A E <br /> ❑ MONITORING GROUT SEAL PUMPEO: LAI Ys [IN. CONCRETE PEDESTAL BY DRIL ER;❑Y.f ON. $ <br /> APPROX.DEPTH 90 feet LOCKING CHESTER BOX/STOVE RPE N/A S <br /> PROPOSED CONS"MnON/ tUNO METHOD: MUD WTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIR APFUCATIOH AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH RAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULER AND <br /> REGULATIONS OF THE SAN MADAN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE FEnroRMANCE OF THE WORK FOR WHICH <br /> TIIIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' COMPACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CEETIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'&COMPENSATION LAWS OF <br /> CALIFORNIA.' THE PPIICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL 9EOURED INSPECEONS AT 1 <br /> Z &1 204YJ422. COMPLETE DRAWING AT LOWER AREA PIODED. <br /> ma"°"X �� - `<-f�—= TRI. Site Project Manager P _ 1 8 D.1._ 6//_/J97 <br /> FIOT PU1N mr.w to Saw.l Bv.l. •tP <br /> 1. NAMES OF STREETS OR WADS NEAREST TO On BOUNDING THE PRORntY. 4. LOCATION OF HOUSE BEWAOE DIBPOBAL SYSTEM OR PIOPOGED <br /> 2. OUTUNE OF THE PFKPEGry,GING DIMENSIONS AND NORTH mnFcHoN' EXPANSION OF BEWAGE DISPOSAL BYSTEMB. <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOWD FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PDUKKry. <br /> 10 <br /> l.r 1 <br /> y L 1 t-- <br /> -1 _ f <br /> 'r03z1 r <br /> I i Y 1 <br /> - <br /> J-- <br /> 1 <br /> GP <br /> t Z It-. <br /> li c <br /> 1 'S '\ <br /> 17S at <br /> 1� <br /> *$De�>_ned n e TrsFinal consent ecree r er, u gmellL dIlU s , <br /> Court on Januu 18, 1996; Section Iv, Paragraph BFAARTMENTU&EONLY '/'/`--"Y} <br /> A.01­11..Aeemlea Py /1/_L <br /> 1 Ar.. <br /> G.,,w Imneellen By Dae Pune Imnmtlen BY Dae <br /> Oe.n.nllen Imnentlen PV <br /> Dae <br /> Dnmma.N: SSG rzn.Ly rL'I.tntio�F-cf' Aoyy1Lf # q---L- 22 —L�/ �- <br /> G <br /> ACCOUNTING ONLY: AID# FAC) <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CARR RECEIVED BY DATE PERMITMERVICE REQUEST NUMBER INVOICE <br /> 2 DI q 2 13 g 5 12 1 6 <br /> Pub.Health Sow.-Enviro.173(1/97) <br />