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. APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, SO4 EAST WEBER AVENUE, STOCKMN, CA SIMI388 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplketel APPLICATMN IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIPS APPLICATION le MADE IN COMPLIANCE WRIT BAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH BEINICES,ENNIIONMENTAL HEALTH DIVISION. JOBADDRESBroRAPN0818 W. Lincoln Road D..Stockton PARCEL SIZEIAPN#097-41-03 SQtt Ing y eaning en ens s 190 OWNER'S NAME C/° Donald T. Bradshaw, Levine-Fricke-Recon ADOREee Emeryville, CA 94608-1827 PHONE 610-652-4500 CONTRACTOR ADDRESS S HCI PHONE e asto of opf ... 57-177681 J07-823-3184 SUBCONTRACTOR_weeks Drilling vsI AoonESB P uc6 PHONE TYPE OF WELLMUMP: 0 NEW WELL ❑ REPLACEMENT WELL 4J MONITORING WELL (1) L' OTHERPilot boring(l) ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑New❑Repd, H.P. DEPTH PUMP GET—FT. FIRST WATER LEVEL 0 (TYPE OF PUMPI ❑ our OM1SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 16 inch DIA.OF CONDUCTOR CASINO 16 inch D 11DOMESTICIPIVATE ®GRAVEL PACKMIZE TYPE OF CASINGISTEEIB'VC steel DIA.OF WELL CASINO 12 inch D ❑ PUBLICBAUNICIPAL EI DRIVEN r2oC, -iLIP rl6k7,tWN OF GROW SEA00- -- "'�`1 SPECIFICAnowement-bentonite R ❑ IRRIGATION/AG ❑OTHER ._-yT0,0 A{ ,yGROUT SEAL INSTALLED y ysy driller GROUT BRAND NAME E ® MONITORING CePAS'/l�IGROVT SEAL PVMPE°:10Y. [IN. CONCRETEPEDESTALBYDWLLER-oY- ❑Ne B APPROX.DEPTH ZOO feet l.�-/�A,1 LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONIDMLNNO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER I HMSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SNALI HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING On SUBCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORL FOR WHICH THIS PERMIT le ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAHFORNIA.' THE APPLICANT MUST CALL 34 HOURS IN�A,DDV�ANCE FOR ALL MODIFIED INSPECTIONS AT 120q 40100421. COMPLETE DRAWINO AT LOWER AREA PTIPTI61emd xc�1 t�ly' C/ l>. Dods E E.^.LL. EJti 4y nor PLAN 10' .•Ie SeNel Beele 'Ip 1. NAMES OF STRE"S OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH vinic w EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED 11M IT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. A-zone®�POot Lincoln Road Q :. .'. Geld _ ®B-zone . ,. LINCOLN ELEMENTARY o� O SCHOOL 0 o 3W FEU *SDCDs Defined in the First Final Consent Decree Orgar.,,4"(A6 and Referenced to Special Master, filed with the Court on January,4 1996: Section IV, Paragraph G. �� A,,11.0len Ae WIN'BT E7/f JLT DFN Z NSo Grein Impeetbn Br DNF Pump Impxllen BY Dots ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO MOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISEANCE REQUEST NUNI RR INVOICE Ifo '247S Pub.Health Sam.-Enviro.173(3196)