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� APPLICATION FOR VVELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVM <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE W(TH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESS/ORAPNI 374 Lincoln Center cITY Stockton PARCELSIZE/APN# 097-41-29 <br /> Settling Dry Cleaning Defendants (SDCDs*) 1900 Powell St. <br /> OWNER'SNAMEr1 nnnald T Rrarlchamt TPVinP-RrirtaP-Rar•nn ADDRESS Fm v-11 - GA 011608-1897 PHONE#Stn-6S9-LSnn <br /> CONTRACTOR ADDRESS UCI PHONE) <br /> 6100 Sebastopol Rd. <br /> SUBCONTRACTOR Woekq Drilling ADDRESS Sehactonal UC#Cq7-177FR1 PHONE17n7-891-21 RL <br /> TYPE OF WEUUMuIMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 Id, OTHER Pilot boring (2) <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑N.0 Repel, H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUTOF-SERVICEWELL ❑ GEOPHYSICAL WELL/ ❑ 601E BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 16 inch DIA.OF CONDUCTOR CASING 16 inch D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC steel DIA.OF WELL CASING 12 inch D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTHOFGROUTSEAL 0-30 Neat cement SPECIFICATION cement-bentonite R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY dri 11 or GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ®Yr [IN. CONCRETE PEDESTAL BY DRILLER:®Vs [IN. S <br /> APPROX.DEPTH 140 feet LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSEELOnOrNGRIL11NG METHOD: MUD ROTARY x AIR ROTARY AVGER CABLE OTHER <br /> 1 well and 2 borings <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL <br /> \24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT(108)4483433. COMPLETE DMWING AT LOWER AREA PROVIDED. <br /> Thl, Site Project Manager <br /> PLOT PLAN IDrew b S.Nal Se)la 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> pEl'IYSBUM1hG RACE <br /> MW5 LVMD#2 IdW2v <br /> LVMD#I MW4 <br /> MW20 <br /> 'R YSaBe uxtt <br /> LVMD <br /> EIEN. <br /> W3 Ml B <br /> MW <br /> MW8 <br /> MWI MW2211 <br /> Pry iia <br /> Former Norge oy MW12 MW9 <br /> Cleaning Yllage Fj, <br /> o CI Cp inesr .'y; 8 <br /> Cart Clrsners <br /> (PSA[ (.O�► oE`d <br /> B/a�/1L� MWII MW10 <br /> AICFr <br /> Chevron lE <br /> Gu gwion Nme --- <br /> y CANFS� <br /> MW7 A Mwe pA� :.. <br /> NWI Exxwomstafim <br /> .d Wily Regal _. <br /> end Wictlend) '. <br /> d <br /> MW-] MW] <br /> S s e Lne Ln lfie FirsEdtal ConsentDecree orcler JucgemenL anu Reterencedto Special Master, tiieu with the <br /> court on Januar 8, 1996: Section IV, Paragraph C DEPARTMENTUSEONLr 7 <br /> Applleetlon Accepted BY <br /> Grout lmpeotlon By Det. Pump lnapectbn By DR. <br /> Deetructlon Impemlon By Do. <br /> n ����/ /' � /I <br /> r <br /> Comments: r "W ✓""- "" "Ata <br /> ri- m6co <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO VNT REMITTED CHECKMASH RECEIVED BY DATE PSWITI8ERVICE REQUEST NUMBER INVOICE <br /> 2 - b Z <br />