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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ., ENVIRONMENTAL HEALTH DIVISION RO, BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA SIMM- 88 1209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete IR Trlplleelel APPLICATION IB ITEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSARIAMI CITY Stockton PAMELSIZE/APU�/097- SETTLING DRY CLBANTdNG DEFENDANTS S�DCDs * Tnc. 1900 Powell St., 12th Floor 41-2� OWNER'e NAMEC O Donald T. Bra Shaw, Levine-Fr ck-Recon 7LDOREeegmG GAS 9116GS-3827 PONEI 0-6 -4 00 CONTRACTOR ADDRESS me PHONES 11350 Monier Park Place SUBCONTRACTOR,S..,.., T„I,..T $aa i.PpHmal#Ka}—GenchemTs*ry ADDRESS Ranch Cordova,CA 95742 m#706568 moNe#916-853-8010 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MGNITORONO WELL B ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑New❑Rrelr ILP. DEPTH PUMP SET—FT. FIRST WATER LEVEL O HYPE OF PUMPI 1�F ❑ OUT or SERVICE WELL ❑ GEOPHYSICAL WELL 4 µ BOIL Bonma VAPOR B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION/ A 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OFWELL EXCAVATION 1-inch DIA.OF CONDUCTOR CASING N/A D ❑ DOMESTICA'NVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/WEELIPVC N/A DIA,OF WELL CASINO N/A D ❑ PUBLIGMUNICH'AL 11 DRIVEN DEPTH OF GROUT SEAL N/A BPECIrICATION Cement-bentonite R ❑ IRRIGATION/AG ❑OTHER FROM SEAL INSTALLED�OBY N/A GROW BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED:AQ Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ON.N/A S APMOX.om"multiple borings 5-45 ft bgs LOCKING CHESTEn BOX/STOVEPIPE S PROPOSED CONWIRUCTION/DRILUNO METHOD: MUD ROTAPIV AIR ROTARY AUGER CABLE OTHERjjydraul iC Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TILE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING ORMIT-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TNM APPLICANT MUST CALL 244 HOURS IN ADVANCE FOR ALL RWMAM 1NSPE�CTIONS AT UMI 4"O n.. COMPLETE DRAWING AT LOWER AREA RgVIDED. Slerod% �C.9—� \lila - _ ) Tllle �1.� 0`^IJVVLLC A/✓ Dele ��c�� . ROT RAN 101.to Soelel Bad. 'to 1. NAMER OF STREETS OR WADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P oPV 6EO 2. OUTLINE OF THE P10RRTY.OIVINO DIMENSIONS AND NORTH DInECT1ON, EXPANSION OF SEWAGE DISPOSAL SYeTEMB. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PIIORRTY OR ADJOINING PIgPERTY. I ApPllaellan Hearted BYJ Id. W'l/� Mr OreN Imerer BY DKs Orb,clron Imnrllan BY— Ode Gammae. 1��W Ess ,-SQL t� ACCOUNTING ONLY: PE CODES FEE INFO ITISERVICE MODEST NUMBER INVOICE D X12 � - *SDCDs Defined in the First Final Consent Decree Order, Judgement and Reference to Pub.Health SON.-Enviro.173(3/96) Special Master filed with the Court on January 18, 1996; SectionIV, Paragraph G.