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APPLICATION FOR WELLIPUMP PERMIT •SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI10 ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompl4to in TripHemni APPLICATION IB HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDroR INSTALL THE WON(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC 81ALT"SERv10ES,ENVIRONMENTSL HE(M.TH OMeq l:ameron St., approx. 132 west o't Gettysburg JOBAODMSSMRAPN# 374 Lincoln Center CITY Stockton PAACELSIZEMPN# Place intersection SETTLING DRY CLEANING DEFENDANTS SDCDs * 1900 Powell St. 12th Floor OWNER'SNAME f rnnyld ASb,� ¢ F ..rte f Pmp-pril Toy .rA 91.604=1577 PHONE#-4510)-652-4 cnn CONTRACTOR ADDRESS 950 Nowe Road UC# PHONE I BURCONTRACTOR Gregg In-Situ, Inc. ADonessMartinez, CA 94533 uc#CA-656407 PRONE# 510-313-5800 TYPE OF WELLA'UMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL#— 11 OTHER ElINSTALLATION 13 WELL SYSTEM REPAIR 11CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J ❑N..v❑ (TYPE OF R/MPI F..I' H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL O ❑ OUr or SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BOnINO B ❑DESTRUCTION: INTENDED USE TYPE OF WELLCON4TRUCTION fPECIFICAnONf A 11 INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL E%CAVATgN -inches DIA.OF CONDUCTOR CASINO NSA D ❑ DOMESTgR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEL/PVC N/A DIA.OF WELL CASINO N/A D ❑ PUBLKRMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL total depth SPECIFICATION cement-bentonite R ❑ IRRIGATION/AG ❑OTHER GROUT BEAL INSTALLED BY contractor DROIT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PIMPED: ®Ys [IN. CONCRETEMOESTALBYDRIIIER:❑Yw ❑Ne S APPROX.DEPIN 80 feet LOCKING CHESTFfl BO%/STOVE RPE N/A B PROPOSED CONSTRUECTTONRXfLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS ARUCATION AND THAT THE"M WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE"We,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION HAWS OF CALNORNIA.• THE APPI ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSFECTIONS AT @OBI 4003/21. COMPLETE DRAWING AT LOWER AREA PROVIDED. 0 81' %— \ Jl� R,'16 — THIF Site Project Manager D.I. PLOT Pun q,nv I.soar Be.I. •Is I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE MKITTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PNOFERrv,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWAYS,AND WALKS. ON THE PRORRTY OR ADJOINING PROPERTY. 38 SE Cwt IV �I IV (' Z E f V yl �e Gl+•1 aM- vJ• �5 t *SDCDs Defined in the First Final Consent Decree Ordg&M %j]6 pnd Reference to Special Master, filed with the Court on January 18, 19965 Section IV, aragraph G APpIIemt%m Aee tW BY. -c,(1 OPVI ImIHRIbn BY D.I. Pvnp ImpevOen Br t DN. D..41.0.n Impeelbn BY D.I. ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PEDMITISERVICE REQUEST NUMBER INVOICE Pub.Health Sew,-Enviro.173(3/96)