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� APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P.O. BOX 386, 904 EAST WEBER AVENUE, STOMON, CA 95201-M (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M Trlpfiestal APPLICATION 1914E BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WOR(DESCRIBED.T11I8 APPLICATION 18 MADE IN COMPLIANCE WRIT BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE88IOR APNE CIT') Stockton PARCELBOEIAPN 097-41-` SETTLING DRY CLEANING DEFENDANTS SDCDs * �or 1900 Powell Street 12th Floor OWNEA'6NAME 0/0 Donald T. RradchaW Levine-Fricke-Recon) Gi%vo Emeryville. CA 946b8-1827 MONEA510-652-4500 CONTRACTOR ADDRESS me PHONE) 11350 Monier Park Place SUBCONTRACTOR Transelobal Environmental Geochemistry ADDREse Rancho Cordova, CA 95742uc# 706568 PHoNc#916-853-8010 TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRONNO WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J ❑N.w❑RR+.I, N.P. DEPTH PUMP BET_". FIRST WATER LEVEL 0 (TYPE OF PVMPI tL�is C3 ow-or SERVICE WELL ❑ OEORIYSICAL WELL# El BOR BORING VAPOR R ❑DESTRUCTION: INTENDED USE TYPE OF WEIl CONfTRUCTION fPECIFICAT10Nf A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OFWELL EXCAVATION 1-inch DIA.OF CONDUCTOR CASING N/A O ❑ DOMESTICA SVATE ❑GRAVEL PACKISIZF TYPE OF CASINO/STEEL/PVC N/A DIA.OF WELL CASINO ❑ Puninc MUNICIPAL 11 DRIVEN DEPTH OF GROW SEAL N/A SPECIFICATION cement-bentonite R ❑ IRRIGATIONIAG ❑OTHER GROW SEAL INSTALLEDBYN/A GROW BRAND NAME N/A E L�J ❑ MONITORING BMW SEAL PUMPED: WYs ❑Ne CONCRETEPEDESTALBYDRILLER:❑Y.. ❑-T/A 5 APPRBK.DEPTR multiple borings 5-45 it bgs LOCKING CHESTER BOX/STOVE RPE $ PROPOSED CONSTRUCTONIORWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERjjvdra Lir push 1"EMERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANO RULES AND REGULATIONS OF THE BAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I 0I4ALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- CONTRACTOR'S HIRINO OR BUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISOM,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUSE IN ADVANCE FOR ALL REOUBEO INEPECTIONG Ai MOIG 4q-fel3. COMPLETE DRAWING AT LOWER AREA PONWED. elam#X \�...11��J iRl. I\Y\1 ro R� J_` PLOT RAN IN.1.BPN.1 Se.ls .' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY PT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Proposed Soil Vapor ®° parcel of Interest 0 too 200 Boring Location - (from Son Joaquin ' I inch = 200 feet Cm fy Aeaeafor'f Nap Book 097 Pape IPJ - GETTYSBURG PLACR 8 ,.•'• 67 • S1 46 .. •.. . .•. 38 00 • 56 0 2 • 0 s (/n DEPARTMENT USE ONLY APPllenbn Aaeep,ed BY � — /`4./ D.R �I I'I L •� M.. Oreu IMP.I1 By O.te Pune ln.peoUen By p.,. De.RncRlen lapeoe.n BY D.le Cemmern.: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVES BY DATE PB TISOMCE MODEST NUMBER INVOICE Dl Pub.Health Sew.-Enviro.173(3/96) *SDCDs Defined in the First Final Consent Decree Order,Judgement and Reference to Special Mar filed with the Court onJanuary 18, ; Section IV, Paragraph G. I