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ti APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 FAST WEBER AVENUE,STOCKTON, CA 95201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (Complete In TFiplkmt4) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANI OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSroR ARM, Emer n Street and Lincoln Road CIV Stockton PARCEL SIZFJAPNI Sett Lng ry ea 19 qwe StreetS OWNER'9NAME c/o Donald I. Bradshaw, Levine-Fricke-ReconAonKs,Emeryville, CA 94608-1827 MONE0510-652-4500 CONTRACTOR ADDRESS IJC# PHONE Weeks Drilling 6180 Sebastopol Rd SUBCONTRACTOR g ADDRESS 310 eatopol Uc#C57-177681 PIONEF707-823-3184 TYPE OF WELLIPUMP• ® NEW WELL ❑ REPLACEMENT WELL SS MONITORING mum(2) El OTHER Pilot boring (1) ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑N. 13 See* H.P. DEPTH RUMP SFE—FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑T OPEN BOTTOM DIA.OFWELLEXCAVATION 22 to 10-inch DIA.OF CONDUCTOR CASINGI8-inch p ❑ COMESTICI'RIVATE J,.�GRAVEL PACKISIZE TYPE OF CASINGRITEUBPVC VIA.OF WELL CASINGI 2-inch O ❑ PUSLICBAUNICIPAL ❑DRIVEN DEPTH OF BEIRUT SEAL to depth of conductOSPECIFICATION cement-bentonite R ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E ® MONITORING GROUT SEAL PIMPED: Elyse [IN. CONCRETEPEDESTALBYDRILLEIR:❑Yw ❑Ne B APPROX.DEPTH 140 feet LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCTION DRILUNO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WMICN THIS PERMIT IS ISSUED,1$HALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA. THLEEAPPLICA1NT MUST CALL 24 HOURSINADVANCE FOR ALL REQUIRED INSMI IONS AT H2OS)44103123. COMPLETE DRAWING AT LOWER AREA POVIDED. G 611n x Il. 1Vrfla5y'poxj 51Wi4.'LFt, DnSfi�P TIB. o.l. •2 I�- PLOT RAN SJI.W.to SoW.I Seel. •le I. NAMES OF STREETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PIOPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND FORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OURJNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY P. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 5 Elmhaven Convalescent _.. 6" Hospital �m o LINCOLN ROAD n i v F E j[{ E R y y � y '.. S SRSNT AVENUE I *SDCDs Defined in the First Final Consent decree Or%,W,,4iV6W&kyand Referenced to Special master, filed with the Court on Januar , 13j19/16, Section IV, Paragraph G. �.T{- V�'1�/y�' ADDIIv.11en A.ewW By J JYa D.I. I / - 1 / A,. a'..MnDevlHn B, D.le PMnP In.DeHlen By DHe De.W.len LNC«Sen Ry DHe C.-m.' : Gds reyocaw-e �ern1L -off enc -� �v,�.ltq!o ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO MOUNT REMITTED CHECKJNCASN VEO BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 0 24 5 �-9� 222D Pub.Health Sew.-Envlro.173(3/96)