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SAIWPPLICATION FOR WELL/PUMP PERM AOUIN COUNTY PUBLIC HEALTH S CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON,CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrIpffe@te) APPLICATION IB HERE BY MADE TO THE SAN JOALIVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Title APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB MORESMR APNO t1 D374�L1incoln Center is g cr" StocktonPacific Ave. frontPAR ERSIZEIAPN# Ben J. Holt Dr. c/ot Don�ld Srarrs�3naDLevn nen Fricke�RecorAooREee Emervv�llel St.�4128h1 Fl�orPHONE f-652-4500 OWNED'S NAME CA 60 -82 CONTRACTOR ADDRESS UCB PHONE B A50 Uowe Road 313-5800 SUBCONTRACTOR Gregg In-Situ, Inc. ADDIIE@e artinez, CA 94553 LTCB A-6� E TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ ❑New❑RmHr H.P. DEPTH PUMP eET_FT. FIRST WATER LEVEL 0 (TYPE OF PUMPI ❑ OM-OF-SERVICE WELL ❑ OEOPLIV6ICAL WELL I to 601E MWNG B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OFMLLEXCAVATMN 2-inches DIA.OF CONDUCTOR CASINO N/A O ❑ MMESMIRUVATE ❑GRAVEL PACKIS2E TYPE OF CASINGRTEEUPVC N/A DIA,OF WELL CASINO N/A 0 ❑ PUBLIC"umcIPAL ❑DRIVEN DEPTH OF GROUT REAL Total Depth SPECIFICATION Cement-Bentonite R ❑ USIGATIONIAG ❑OTHER SMUT SEAL INSTALLED p BY Contractor BMW BRAND NAME N/A E ❑ MONITORING SMUT SEAL PUMPER:EJY. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw (IN. S APPROX.DEPTH 80 feet LOCKING CHESTER BO MOVE PIPE N/A S RLOMSED CONSTMeTIONAI LUNO NUMB: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push 1 HEREBY CERTIFY THAT I HAVE PPEPAREO THIS APNJCATMN AND THAT THE WOR(MU-BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY OMINANOEO.STATE LAWS,AND RULE@ AND MMIATMNS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWINO:•1 CESTIFY THAT IN THE PIR AMANCE OF THE WOR(FOR"ICH THIS PERMIT IS ISSUED,I MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMRACTOR'S HIRING OR OUB-CONTRACTING SMNATUIIE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT m THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE CANT MUS�jT/LL/b1 MtmS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT M0@I 140.0\20. COMPLETE DRAWING AT LOWER AREA PROVIDED. ema X9 ./.[.� /C.d�.S'L..� z nGe Site Project Manager Ott. 6//2-197 PLOT PLAN IN.m ear.)Seele •le 1. NAMES OF STREETS OR MADS NEAREST TO OR BOOMING THE PROPERTY. 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH INFECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. S MENtOGRED OUTUNEB AND LOCATION OF ALL EXISTING AM PROPOSED S. LOCATION OF WELLS WITHIN Motu@ OF ONE HUNDRED FIFTY FT. ..._ ^- ^•♦•tea urn WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 11U� Cleaning Village ..J.�t Oy \\\\�\,\\\\\✓//// � Fortner Finest 11 o� \ Care Cleaners ?A 0 e MW 10 B v� MW l l Y A/C1oT MW-5 Chevron �E Gas Station MW-3 g C- 10* p` MW3 MW-6W7 M6 CP00CCPT plPoT-1 M o Mw-1 Exxon On Station MW-9 (formerly Regal - . 3,'k O11 ''�� and Wickland) S4Txx� A � Wa SMa, A MW-7 MW-2 MW-3 MW-10 B� MW-8 MW.11 *S15 a ned in the First Final Consent Decree Order Tudement and Reference to Special Master, filed with the Court on Januar -,±8 1996; Section Iv, Paragraph GDEPAR}M7NY tlOF ONLY A,Ik.tl.n AeegtM BT Del. -?�•l• L M.. G.erA BelNaaen BY Mt. PKPP Io.P:Den By Not. owPmllen ImpwllPn BY Dae ee ae.: CL+"►E>� st�ktoE\ �h��E hvL.aF-t R ,.t,* �& ,13zq j�c4 3o�i re�cl:a&S 1 ACCOUNTING ONLY: AID/ FACS DECODE@ FEEINTO MOUNT REMITTED CHECKMAM RECEVED BY DATE PEVAITISERVICE REQUEST NUMBER INVOICE GI J6 -1 96752, Pub.Health Sew.-Envlro.173(1/97)