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1 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> •SAN JOAQUIN COUNTY PURLIC HEALTH SERVI10 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (2091468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In TrlplkelGl <br /> APPLICATION Ie HISS BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 08 MADE IN COMPLIANCE WHIZ BAN <br /> JOAQUIN COUNFY DEVELOPMENT TITLE,CHAPTER 0-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> Stanton Way - 1001 west of <br /> JOBADDRESSOn APNF 374 T.inroln Center CITY Stockton PARCELSIZE/APN#CpftyshUrE Place <br /> Settling Dry Cleaning Defendants (SDCDs*) 1900 Powell Street <br /> OWNER'S NAME _ ___ __ _ __ ADDRESS Emeryville, 6A 94608 1:829 PHONE/ 510-652-4500 <br /> CONTRACTOR ADDRESS LICF RHONE# <br /> Howe Road <br /> SUBCONTRACTOR Gregg Drilling & TestingII-��11 ADDOEBB Martinez, CA 94553 LIC(CA 495165 PHO <br /> ONEFSI -3l3-1800 <br /> TYPE OF WEMTLIMP: L.N NEW WELL ❑ REPLACEMENT WELL W MONITORING WELL F ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑New❑Sev.I, H.P. DEPTH PUMP SET_FT. "It"WATER LEVEL O <br /> RVPE OF PUMP( <br /> ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL F ❑ BOIL BORING 8 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPENSOTTOM DIA.OF WELL EXCAVATION 19-inch DIA.OF CONDUCTOR CASINO 1�0II O <br /> ❑ DOMESTICIROVATE ®GRAVEL PACK/SIZE TYPEOFCA61NOISTEEVPVC PVC & steel DIA.OFWELLCASINO 4-inch D <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTHOFOROUTSEAL L5 Fcct SPECIFICATION C20PIIt-1`�^FLYlitl: R <br /> 0 IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY driller GROAT BRAND NAME E <br /> y.l MONITORING GROUT SEAL PUMPED: QYs ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yr (IN. 5 <br /> APPROX.DEPTH 80 feet LOCKING CHESTED SOX/STOVE RPE S <br /> PROPOSED CONSTRUGnONtMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> 1 HESERY CERTIFY THAT I 1/AVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 18 ISSUED.IBI/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFENNATHON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUD CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.- THE APPLICANT MUST CALL 24((DABS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I30q 4p0/E1. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Till. Site Project Manager D.I. L\ y <br /> PLOT PLAN RN.1.SoYel Bates 'le <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROIOBED <br /> Z. OUTLINE OF THE PO PERTY,OIING 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 WALK$. ON THE PROPERTY OR ADJOINING POPERTY. <br /> D <br /> C <br /> C 0 <br /> LINCOLN ROAD w a'c`G <br /> u2Za <br /> Om <br /> N <br /> za x <br /> FCC <br /> Q <br /> J <br /> I° a8 <br /> STANTON NAY <br /> U 8% <br /> aB _ <br /> A <br /> Ell z o F= <br /> 0 <br /> J. <br /> w s <br /> s a Lneci in the il ConsentDecree 0r er Ju gement an Referenced to Special Master, filed with the <br /> Court on January 18, 11�19�9/6,,y,Section IV, Paragraph (VEPARTMENT USE ONLY 4 �/'I� <br /> AP,lla.ebn AFoePeed By / F T !V Ag/ //iF D.1._ 1.`5 j�L A,.. <br /> areal Imveelbn By Dae Pt my In.omelen BY Daa <br /> Oe.vRNBen IdvecBon By _ D.I. <br /> Den,n,aS.: SSG s�rYoccyLn�-t ey,N(L � q�- IZS.L1/ <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PFRMITI$MMCE REQUEST NUMBER INVOICE <br /> -211,0 (23 14 <br /> Pub.Health Serv.-Enviro.173(3195) <br />