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►s • APPLICATION FOR WELLIPUMP PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICS ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201588 (209) 4653420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ICempleu In TrbRMtel APPLICATION IS(HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION. McClellan Wy approx. 400' west of Gettysburg JOBADDRESSIOR Am# 374 Lincoln Center CITY Stockton Book 0971)43 PARCEL SIZEIAPN/PlaCE Intersection Settling Dry Cleaning Defendants SDCDs* 1900 Powell St. 12th Floor 510-652-4500 OWNER'S NAME / n lA T A A h T i F i L A �.00REeB_� alo nrilIo 'GA 9h608 '927 RHONE CONTRACTOR ADDRESS HCI PHONE It- SUBCONTRACTOR SUBCONTRACTOR Gregg In-Situ, Inc. ADOncee 950 Howe Road 94553 uc656407 PH / CA- ONE/Sl0-3l3-SRpO 24Rr1:Inez, E.k TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPIACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ ❑New❑Nenalr HVFE OF MMPIH.P. DEPTH PUMP GEi FT. FIRST WATER LEVEL p p ❑ OUT or BERVICE WELL ❑ GEOPHYSICAL WELL/ 3P FOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIOMe A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OFWELL EXCAVATION 2-inChes - DIA.OP CONDUCTOR CASING /A D ❑ OOMESTICN VATE 11 GRAVEL PACK/SIZE TVR of CASINWRT,,RVC N/A OIA.OF WELL CASINO N/A O ❑ PUBLICRAUNICIPAL ❑)DRIVEN MPTHOFOROUPMAL total depth RRCIFICATIONrPmPnt-hones'nnit R ❑ IRRIGATION/AO El OTHER GROUT SEAL INSTALLED BY contractor GROUT BRAND NAME N/A E ❑ MOMTORINO GROUT REAL PUMPEO: ®Y. [I Ht, CONCRETE PEDESTAL BY DRILLER ❑Ys [IN. S APPROX.MVTN 80 feet LOCKING CRiLSIER00X/STOVE RR N/A $ PROPOSED CONS"MnONI LUNG METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHEP-Eydraul i Push 1 HEREBY CERTIFY THAT I PIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOVIN COUNPY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOLMNG:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR MUCH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUD CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMANi COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MMUBT CALL 24 ROUND IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IZMI 4411 t22. COMPETE DRAWING AT LOWER AREA PROMISED. The Site Project Manager POT PUN IDrew le Betel Bede 'le I. NAMES OF STRETS OR ROADS NEAREST TO OR BOUNDING THE PIUPESTY, 4. LOCATION OF HOUSE SEWAGE OIBPOSAL SYSTEM OR MMSED Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLWFS 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 PROPERTY OB ADJOINING PROPERTY. It �N Q, At �T tAc Glel u"" 818 .r' Y) SDCDs Defined in the First Final Consent Decree 0WANJ %tyand Referenced to Special Master, filed with the court on January 18, 19v96�,�Section JV, -Paragraph G A"11.lien Aaet,,1W BY / T l 1 D.H. `I'I pL-�-I At. a`t OroA BRPeellen BY de PmnP I.P.O..BY D.t. DeHnalbn SnnecHlen BY Oele ACCOUNTING ONLY: MO/ FAO# PE CODES FEE INTO AMOUNT REMITTED CHECKMASH RECEIVED BY /D/ATE PEPINITISMVICE REQUEST NUMBER INVOICE Pub.Health SEN.-Envlro.173(3/96)