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APPLICATION FOR WELLIPUMP PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209) 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I APPLICATION R 14ERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTANDIOB INSTALL THE WOR(DESCRIBED.THIN APPLICATION IS MADE IN COMPLIANCE WHIT SAN JOAUUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# Emer n Street and Lincoln Road Stockton Sett ing ry eamng a en ens s lq0 PARCEL 812EJAPNI OVMEn'BNAMEC oDonald T. Bradshaw Levine-Fricke-Recon ADOREe�mer yville, Cel 94608-1829 PHONE#510-652-4500 CONTRACTOR ADDOE88 UC! 6uB coNrracioq Gregg Drilling & Testing Inc. ADDRESS MPHONE#Martinez, CA 94553 ucEA485165 RIoNe#510-313-5800 IAL TYPE OF WELL/PUMP; NEW WELL ❑ nEMCEMFNT WELL ® MONITORING WELL# ❑ C INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR 11 OTHER ❑New❑ H.P. 11VAPOR EXTRACTION WELL/ Raelr RVPE OF UMP) DEPTH PUMP SET__FT, FIRST WATER LEVEL ❑ DESTRUCTION; FRIOUT-OF WELL ❑ GEOPHYSICAL WELL A ❑ SOIL BONG O fl INTENDED USE TYPE OF WELL CONBTgUCT10N SPECIFICATIONS ❑ INDUSTRIAL A1-1Y OPEN BOTTOM DIA.OF WELL EXCAVATIONI2-inch A C1 DGMESTICIPNVATE 19GRAVEL PACKISIZE DIA.OF CONDUCTOR CASINO O TYPE OF CASINOISTEEU'V(pvr LcY 7 DIA.OF WELL CASINO 4-inch ❑ URUCIMUNICIPAL ElOnIVEN DEPTH OF GROUT SEAL 45 feet o SPECIFICATION cement-bentonite q IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY ��R.iiff driller MONITORING GROUT BRAND NAME E PROP 113{ ROS.DEPTH GROUT SEAL WMMO.-Myr ❑Ne CONCRETE PEDFBTAL BV DNLLER:❑Y. ❑N£ 8 LOCKING CHESTER 6OXISTOVE RPE PROPOSED CONSTgVCT10N/dSWNO METHOD: MUD ROTARY S AIR LOCKING AUGER CABLE OTHER_ 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS AIYUCATION AND THAT THE WOOL WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN CLAWS,AND RULER AND MOULATOOUNTY ORDINANCES,eMTE NS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE E THE WON(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONO SUBJECT TO WORKMAMS COMPENSATION LAWS OF CALIFORNIA.' COMRACTOR'B HIRING THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IB ISSUED, OR BUB-OUR-CONTRACTING SIGNATURE CErtTIREe I OR EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 34 HOURS IN ADVANCE FOR ALL REQUIRED INSMIDONS AT 114004M22, COMPLETE DRAWING T LOWER AREA RXIVIDED. 810 nn. . D.1.3�a��4� 9 a PLOT MN ROPE le BOYeI%.I.RO •ro I. NAMES OF STIKETB OR ADS NEAREST TO OR BOUNDING 111E PROPERTY. 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF I4OUSE SEWAGE DISPOSAL SYSTEM On PROPOSED S. DIMENBbNEO OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF BEWAGF DISPOSAL SYSTEMS. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WAIKe. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY On ADJOINING PROPERTY, m£ s 6$ ' Elmhaven Convalescent Hospital �a g :.....J..... p LINCOLN SOAR £ e o R £ E � g> E 0 X Qr�G O 4 o a SRENT AVENUE Dsa i ned in the Trst T.na onsent ecreer er u gement an a erence o pec>.a aster, L. a e Court on Januar id 1996, Section IV, Paragraph GP"ARTMENr USEONLY wt. ARPllalla AeeePlal By / F L _�.I-�J -!S- / D£1._ Ara Grein lrnoalbn BY D£la •n•Pw.•cr 6Y UNe Owlrwllan ImPallon BY �* 64210 DSM �emm��.:�p�cNOGchnAoL�F pe,�Llt2xP 51�I � `F I1eLlo<ab(a pFyrolLt R� o� 6rt (p ACCOUNTING ONLY: NDA FAC# PE CODU FEE INFO AMOUNT REBUTTED CHECXEOASH RECEIVED BY DATE PERMITISTRVICE REQUEST NUMBER INVOICE Q-22 L Pub.Health Sew.-Enviro.173(3/96)