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APPLICATION FOR INELLIPUMP PERMIT •SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 12091468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrItHentel APPLICATION IB HERE BY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TAPS APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 81115.3 AND THE STANDARDS OF BAN JOAMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR ARI( i74 7.1nCOln Center cm, Stockton PARCEL SIZEIAPNFB. Holt/Gettysburg SETTLING DRY CLEF P �hFEfdDAt;'PSZSIIC17s 1 CA 94608 OWNER'S HAMEC/O Donald T. Bradshaw, Levine-Fricke-Recon �IRAHE9A 1900 Powell St., 12th F1r.Emeryville CNF�TO_6Kv_Lsnn CONTRACTOR ADORsss UCI PHONE( SUBCONTRACTOR Transglobal Environmental Geochemistry 11350 Monier Park Place Cordova CA95747 ucg06568 PHoNE616-853-8010 TYPE OF WELLrFUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL♦ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL# J (TYPE OF PUMP( ❑New❑R.pslr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ Out-or SERVICE WELL ❑ GEOPHYSICAL WELL A ® SOIL BORING VAPOR A ❑DESTRUCTION- INTENDED USF -----TYPE CONSTRUCTION 8PECIFICATIONt A ❑ INDUSTRIAL ❑OPENBWFOM DIA.OF WELL EXCAVATION 1-inch DIA,OF CONDUCTOR CASINO N/A D ❑ DOMESTICWRIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINO/STEELPVC N/A DIA.OF WELL CABINS N/A D ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL N/A SPECmCAT1ONcement-bentonite A ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY N/A GROUT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED: ®Ys [I N. CONCRETEPEDESTALSYDRILLER:❑Yr ❑HeN/A S APPROX.DEPTHmultiple boring's 5 t0 45 ft bgs LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONSTIIICTIONIDPILLINQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS AFMICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY OPDINANCES,STATE UWP, NO RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:T CERTIFY THAT IN THE PERFORMANCE OF THE WOW FORWHICH THIS PERMIT IS ISSUED,1914ALL NOT EMMOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'8 HIRING OR BUDCONTRACTING SIGNATURE CE"SIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,P SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUFT CALL 24 HOURS IN AOVANCE FOR ALL REOURM INSMIDD AT VKHH 4" 26. COMPLETE DRAWING AT LOWER AREA PA OVIDED. TB1e !!y �Yo AO��1 Do,. \ —�— PLOT MAN to,.to%W.)BPa. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROMRFY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PMbPOSFD 2. OUTLINE OF THE PgMRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S- LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY ET. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. GRITYSBURC PLACE SSG L I I DBMTMBIT use ONLY ApPll.eRlen Aeeepl.A BY /�'f DPf N Aru Gr.w Impeellen B,. . not. MmP IDE.. 11-M BY Das D..veeeen l..n..G.n BY Dae Gammen,.: SL Sn�L-coLh"1rW�Y1¢ r rt q7 g ,4 LV (? U, ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO MOUNT R TED CHECK#/CASH ECDVED 0Y DATE PERMITIe FRVICE REQUEST NUMBER INVOICE 24ir✓ n �'� Pub.Health Serv.-Enviro.173(3/96) *SDCDs Defined in the First Final Consent Decree Order, Judgement and Reference o Special Master filed withthe Court on January 18, 1996; Section IV, Paragrph G.