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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P,O. BOX 386, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 499-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUER (Complete in TrolkRte) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNB INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WHN SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH 0IV1810N. JOB ADORESBNR APNI 174 er cmv Stockton PARCEL SIZE/APN 97-4 �S1-2( SETTLING DRY CLEANING DEFENDANTS s 1 awe street, or OWNER'S NAMEc/o Donald T. Bradshaw- Levine-Fricke-Recon 68e Emeryville, .CA 94608-1827 PHONE 510-652-4500 COMPACTOR ADDRESS UCI PHONE# Run coMRAeTonTransglobal Environmental Geochemistr111350 Monier Park Place o ADDRESS Rancho Cordova, CA 95742uCI 706568 MONEP16-853-8010 TYPE OF WELLIPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F ITYR:OF PUMP) ElN.❑P&R,* N.P. DEPTH PUMP BET FT. FIRST WATER LEVEL D .,1m 11 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL F X® SOIL BORING VAPOR e ❑DESTRUCTION: INTENDED USE TYPE OF CONSTRUCl10N SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1-inch DIA.OF CONDUCTOR CASINO N/A 0 ❑ DOMESn(sPNVATE ❑GRAVEL PACIUSIZE TYPE OF CNRINOISTEELJPVC N/A DIA.OF WELL CASING N A D ❑ PUBUCIMUMCMAL 11 DRIVEN DEPTH OF GROUT BEAL N/A SPECIFICATION cement-bentonite B ❑ IRRIGATION/AG ❑OTHER GROUTBEAL INSTALLED{{,�-B-AIY NIA GROW BRAND NAME N/A E 11 MONITORING GROUTBEALPUMPMEl Yo ❑N. CONCRETEPEDESTALBYDRILLER:❑Yo ❑N.N/A s APPROX.01PTH multiple borings 5-45 £t bgs LOCKING CHESTER BOX/STOVE RPE $ PROPOSED CONITRUCTION/ORLUNO METHOD: MVD ROTAIIY AIR ROTANY AUGER CABLE OTHER HydrAo 1 i c Push 1 HE"EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND "FOLIATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PLRFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NOUNS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT IMI 460. 22. COMPLETE DRAWING AT LOWER AREA PROVIDED. 61'm X \ILK�....9�� \ - �L�.- � T10. \'Y' 14 d\A.. 1`�OhpC R- D.ta C L PLOT PUN 0.to%W.)%.I. 'to 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE FROMM. 4. LOCATION OF NOVBE SEWAGE DISPOSAL SYSTEM OR PRiOR'pBED 2. OUTLINE OF THE PNOPERTY,OIMM DIMENSIONS AND MITIN DIRECTION. EXPANSION F SEWAGE WAGEDISPODI SYSTEMS. 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN SAL S T ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIKS. ON THE PROPERTY OR ADJOINING PROPERTY. A n I II I I ® I I 20 1�, - ® Proposed Soil Vapor ® I.� V,U IS Boring Location N �e Parcel of Interest0 60 120 y '� b 64 48 I I imh = 120 feet (from San Joaquin `-J Cuun(V AEBPevaF's Nap Book 097 Paye 41) 7 - - PACIFIC AVENUE DEPARTMENT USE ONLY Aoonean Aetd Br_ 4Ae Aro Grout Knpeetbn Br Dee Pune lmeee@on SP O.t. OomcBen Imlotbn Br D.ta CemmsAn ACCOUNTING ONLY: NDI FACF PE CODES FEE INFO AMOUNT REMITTED CMCKI/CA6H RECEIVED BY DATE PLEPMTIIFNVICE PEOVE6T NUMBER g d Re erene *SDCDs Defined in the FirstAConsent Decree Order, Judgement anco Pub.H@atth Serv.-Enviro.173(3/96) Special Master filed with the Court on January 18, 1996; Section IV, Paragraph G.