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SAIWPPLICATION FOR WELL/PUMP PERM Rery l i+ 1 v)JU& S AOUIN COUNTY PUBLIC HEALTH SEES Cir s+211 . S:�5 W of(yQl l? ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 CPT 4 zl5- 155 'W 04- (209) f(209) 468-3420 NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATE ISSUED ICampl41u In TripREEu) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THUS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSM AFRI 374 Lincoln Center cITY Stockton McClellan Way approx 1120' W Gettysburg Pl. PARCEL SIZUAPN# Settling Dryy C eaning a en ents s 1900 Ppwell St, 12th Floor 510-652-4500 OWNERS NAME c/o Donald T. Bradshaw, Levine-Fricke-RecopDORESS erwille,. A 44 8-1827 PHONE# COMPACTOR ADDRESS UCI PHONE I V0 yowe Road 510-313-5800 BUS CONTRACTOR Crede Tn-Sim Inc. ADDRESS artTnez, CA 94553 uc• CA-656407 PHONE# TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑New❑Repel, H.P. DEPTH NMP SET—FT. HART WATER LEVEL O R VPE OF MMPI 11 13SOILWELL 13GEOPHYSICAL WELL# .W ROIL PORING B ❑DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CASINO N/A D ❑ DOMEBTICIPIIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/FVC N/A DIA.OF WELL CASINO N/A D ❑ NRUC/MUNICIPAL El DRIVEN DEPTH OF GROUT SEAL Total Depth SPECIFICATION Cement-Bentonite R ❑ IRRIGATION/AG y/OTHER GROW SEAL INSTALLED �BvY Contractor BMW SHAM NAME N/A E ❑ MONITORING GROW SEAL PUMPED:t3V. (IN. CONCRETE PEDESTAL BV DRILLER:Ely. (IN. S APPROX,DEPTH LOCKING CHEBTER BOXAITOVE PPE N A S PROPOSED CONSTRUCTIOM)RILNNG METHOD: MUD MTMIY AIR VOTARY AUGER CABLE OTHER Hydraulic Push 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH RAN 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 IB ISSUED.I814ALL NOT EMPLOY PERSONR SUBJECT TO WORKMAN-@ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR AU"ONTPACTING SIGNATURE CERTIFIES THE FOLLOWING: .I CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY MITSONS SUBJECT TO WORKMAN'S COMPENBATION LAWS OF CALIFORNIA.- TNF CANT MUSTC//ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSM17TIOM AT 120411 489) 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. TRs IS Site Project Manager D.1. 6/ /L(97 PLOT PUN In-1.Spiel IBM. •ro 1. NAMER OF STREETS OR ROADS NEAREST TO OD BOUNDING TINE FROPEnTV. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. OUTLINE OF THE PIOPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTUNFB AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PIOPERTY. _ i� - - + pr PY-z1S i 1 C - 11 •�c1 _ 101 i LRT- :_- , 1 OZ�, b73z; i 1161' R 1. ',; _ , • 5i � 1 , , 1 tPT-ZI6 ef *SDCD: Defined in the First Final Consent Decree Order Judgment an Reference to Special aster, filed wit e Court on Janus 1 ; Section TVParagraph GoFPAB;MENT USE ONLY --7 $ Appnc.Rnn Ae~W Br VSTo D.a • - I- J A,Y ma,A Inev..Ron By Ow. FUnF Inevvelbn By O.la Um,ncllon IrnP+elbn By Dae c.m,n.,W 53C cncrvacy�vne✓�1' e%vtl� 22(v- L �KIL-eS /0 l5• -1- LPT -t'I 2 11 , 4421,✓ r 21 ACCOUNTING ONLY: AIDI FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SEANCE REQUEST NUMM R INVOICE 2`lni 2q13 -85 2A $ Pub.Health Sew.-Enviro.173(1/97)