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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERIW ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CDmpktE In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Stockton PARCELSIZE/API#B• Holt/@ Lincoln JOB ADDRES6IOR AP N# Lincoln Center CITYStockton 94 enter SETTLING NG DRY CLEANIN DEFENDANT s OWNER'S NAME ^/^ Donald T Bradshaw Levine-Fricke-Recon ADDRESS1900 Powell St 12th Fir. Emeryville.PHONE# (510)652-4500 Inc. CONTRACTOR ADDRES6UC# PHONE# ower ar ace (9IZT— SUBCONTRACTOR Transglobal Environmental Geochemistry ADDRESS Rancho Cordova, CA 95742 L1c# 706568 PHONE# 853-9010 TYPE OF WELLIPUMP: [INEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Repair N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑.OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ID SOIL BORING VAPOR e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION 1-i Doh DIA.OF CONDUCTOR CASING NIA 0 ❑ DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPEOFCASING/6TEEL/PVC MIA DIA.DIA.OF WELL CASING atj&_ 0 ❑ PmUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL N/A SPECIFICATION cement-ben toni to R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED B'IV N7A GROUT BRAND NAME N/A F Cl MONITORING GROUT SEAL PUMPED: P Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ON-N/A S APPROX.DEPTH multiple borings 5 to 45 ft bgs LOCKING CHESTER BOX/STOVE PPE S PWWEED CONSTBUCTION/WSWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE PPUCANT MVSTCALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20S1400J 28. COMPLETE DRAWING AT LOWER AREA PROVIDED. BIeroJ X /� /% �' "—� Title Sit PYDIQ„pC Ma oeY O.te / I RIOT PAN M,.W t.epaiel Se.la 'tp 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL EYMM OR PROPOSED 2, OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. "' V -4 ' S 1N �H ®® z ® Q 4 U JBES,AMIN HOLT DRIVE ® qu v u ® (U M _ ® .Cr v o *SDCDs Defined in the First Final Consent Decree Order Judgement and Reference to Special Master filed with DEPARTMENT USE ONLY I/�Q t�ovlmatParAtEe opjanuary 18, 1996; Sec on IV, Paragraph G. De. 'QY(/' {'� A,. Gann In.pectlen B yg By Dae Dmtnntlpn In.,e ,Ibn By D.te Cemmeet.: S"�G �L,t'Y.y'uLGVLVI1e.✓lJF' {�V✓T1t-I' ?�"'��—�—V tSSLs.¢cl 5 Z1•rl�' CxPtveS �' S`�� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY GATE PERMIT/SERVICE REQUEST NUMBER INVOICE �(2�Li