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PLICATION FOR WELUPUMP PERM SA AQUIN COUNTY PUBLIC HEALTH SE ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplefe In TdnikuFl APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.Title APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Joe ADDRESaroR APNI 374 Lincoln Center CITY Stockton Vicksburg Pl. approx Xa corner of Vicksburg PARCEL SIZE/APHE& MCClellen Settling Dryy eaning a en ens s 1 owe oor 510-65240 OWNER'S NAME_ c o Donald T. Bradshaw, Levine-Fricke-Recopmmse Emeryville, CA4608-1827 PHONE COMPACTOR ADDRESS INTI PNINEI owe 5jp—erg_, s� BUB CONTRACTOR Gregg In-Situ, Inc. ADDRESS Martinez, CA 94553 ucI CA-656407 PHONEI TYPEOF WELLIPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTIIER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECTREPAIR ❑ VAPOR EXTRACTION WELL I 11New❑Ppelr H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O (TYPE OF LIMPET GGS�II 11OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL/ 13 BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CASING NSA O ❑ MMESTIC/PIIVATE El GRAVEL PACK/SIZE TYPE OF CASING/RTEELIPVC_N/A DIA.OF WELL CASING N/A O ❑ PUBUCMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL Total Depth SPECIFICATION Cement-Bentonite B ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Contractor GROUT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED:f2Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne S APPROX.DEPTH 80 feet LOCKING CHESTER BOX/STOVE PPE N/A S PROPOSED CONBTRIICnONIDRIIUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERHYdraLLliC Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE UWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'e SIGNATURE CERTIFIES 714E FOLLOWING:'I CEMIFY THAT IN THE PERFORMANCE OF T11E WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION UWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE wom FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THEA ANT MUST CA ZS HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IT l SSSJAfS. COMPETE DRAWINO AT LOWER AREA PROVIDED. Sllr�X Al.� �� TIIIe_ Site Project Manager D.I. 6/1_/97 Pot PUN ID'.w to sore)%.I. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OB PROPOSED I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB, G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAUCS. ON THE FROPERTY OR ADJOINING PNOPEGTY. Vll oz i 1 � ) R ! : yea 1/ LI� J ! •y� ,, '` `,,1 ,i • !y +'T _ v 1 �'I i1Z Y b z �3 pr-2 1-a •c F----- -_.- N�� - `• ;--'' Nps. ,.-;''" ''`, SIE 1, 6 ' 1 T *SD-CD�e�ine3in Ene first - ins onsen Scree r er, m n an er , Court on 8 Janus 1 ,\,7199,61;'-Section Iv, Paragraph IFPI!RTMENT USE ONLY AUP11eeSon Aaoevtd By 'J r�1/yQ D.t. / - LJ' l � Ar.e Grow ImPmtlen By Oete P P p Imveetlen By Mta De.erKGen L,.neeRen By Dete Demme.,H: 5�) C ontcl�.y t' eVYYti - 22L�25 fD.l5• �- C.P T 218 Pct OUNTINO ,NLV: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECKIICASN RECEIVED BY DATE PEHMITISFRVICE REOUEBT NUMBEII INVOICE � 2 13y O Pub.Health Sew.-Enviro.173(1/97)