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APPLICATION FOR WELLIPUMP PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 3N4 EAST WEBER AVENUE, STOCKTON, CA 9MI0 W8 (209) 4003420 NON-REFUNDARtE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CompMte In TrIp)kntB) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMn INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH ° aq�BERUC NPI ENTH TH 0 JOBADDRESSIORAPNB 374 Lincoln Centerarap�Y�b�L. MJ"'west of SET N DIrr Stockton PARCEL sIzvAPNFGettysburg Place OWNER'S NAME r/O nnn ld T n d h^ T tI F L s 19 owe t, t OOr ntersec ion Rr 1B�9DIRM Fpm ryyi]]P .(`A 94r,08-1877 PHON"JL511) CONTRACTOR ADDRE Do..990 44960- HO@- MN RHONE) .BUB COMRACTOR Gregg In-Situ, Inc. ADDnEBB Martinez, CA 94553 m, CA-656407 m,,,,510-313-5800 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 ❑New❑ J Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL HYPE OF PUMP) I-� O 11 OUT or BERVICF WELL ❑ OEOm1YSICAL WELL I yy BOIL BORING B ❑DESTRUCTION: INTENOEO USE TYPE OF WELL CON$TRUC TION SPECIFICATIONS ❑ INDUSTRIAL ❑OPENBOTTOM -inches A DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING N/A D ❑ PUBLIC UNICIPAL GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVC N/A DIA.OF WELL CASING N/A ❑ 1'UBLICR.IVNICIPAL DRIVEN D qq DEPTH OFOROUT LLE total depth SPECIFICATION cement-bentonite B ❑ IRRIGATION/AO Ly OTHER GROUT SEAL INSTALLED BY rnntrantnr GROUT BRAND NAME_ ❑ MONITORING GROUT SEAL PLIMPEO: [MY. [IN. CONCRETE PEDESTAL By DYEly. ❑N. S APPROX.VFPIH LOCKING CHESTER BOHIM'. `�E PIPE_NI/A_ PROPOSED CONSTgUCTIONRXBWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER drallllC HyPush S I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY UROINANCEB.STATE LA,,'AND RULER ANO REGULATIONS OF THE BAN JOAQUIN COUNTY, NOME OWNER OR LICENSED ADEM'$SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WOW FOR WHICH THIS PERMIT IB ISSUED,1914ALL NOT EMPLOY PERBONB SUBJECT TO WORKMAN-$COMPENSATION LAWS OF CAUFOAMA.' CONTRACTOR'S HIRING OR OUR CONTRACTING SIGNATURE CERTIFIES TIIE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISRUED,I SHALL EMPLOY PERSONS SUBJECT TO WORpWAN'S COMPENSATION UWe OF CALIFORNIA.' THE A CANT MUSTTC�CALL //14 HOURS IN ADVANCE FOA ALL REGU IM INSPECTIONS AT)MBI 4BBJ41X. COMPLETE DRAWING AT LOWER AREA PROVIDED. eloma X_�/� TIO.Site Project Manager — /7�9 DW. L PLOT PLAN IM.I.%W.1 6p.1. 1p 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIE PROTETITY. 4. LOCATION OF IIOUBE SEWAGE DISPOSAL SYSTEM GR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF 4OUSEGENVAS WAGE DI SYSTEMS. G. DIMENSIONED OVTVNF.e DING LOCATION OF All EXISTING AND PHOPOBEO S. LOCATION OF WELLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRMTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAY8,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERry, r N i ad- All Main ddd � tl �� . . I ' �. .Vie Glc,OA-- WIN L1DCL vr7 �)�u• *SDCDs Defined in the First Final Consent Decree OrgUA,,yWf p� &d Reference to Special Master, filed with the Court on January 18, 1996; Section IV, ✓P�pr�agr�a_ph Gr [/ Appllwlbn AcpeplM BY r ' I,1 (/z�yLYl %� O.I. T A,.. Gr.u1 Impmeen BY Go. Imp Impe.Ilen BY D.\e DmmNnen Imn.pnen er ------------- D.Ie ACCOUNTING ONLY: AID/ FACS PE CCv�O�OEB FEE INTO AMOUNT REMITTED CFIE/C^X /C IA911 RE �ClEIIV^ED BY DATE PERMITISER1VICE REQUEST NUMBER INVOICE 1O Pub.Health Serv.-Enviro.173(3/96)