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APPLICATION FOR INELVPUMP PERMIT *SAN JOAUUIN COUNTY PUBLIC HEALTH SERVIC 01 ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA VSM- 88 (209( 409.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripReete) APPLICATION 19 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY MBUC HEALTH SERVICER,ENVIRONMENFAt HEALTH DJVI¢1QN. �� JOBADDRESSMRAPHo 374 Lincoln Center Stockton 21YO• ' -97-41-7: CITY SETTLING DRY CLEANIN DE END N s 1900 Powell St., 12th Floor PARCEL SIZFJAPNO OWNER'SNAME c/o Donald T. Bradshaw, Levine-Fricke-RecoTylD I d8rmo,-3,�1i<� rA oea09-1821 PHONEI5I0-699-6500 CONTRACTOR ADDRESS LOCO PHONE O PUB CONTRACTOR TTanSPlObal Environmental Geochemistry 11350 Monier Park Place ADOMOSRanrhn rnrdnva,r'A 05749 UCO 70(, /" PIHoNEB16-854-8010 TYPE OF WELLNUMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAI9 ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL F TYPE OF MMPI ❑N.El flp.lr H.P. DEPTH NMP RET ". FIRST WATER LEVEL G ryry,T ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL O YJ SOIL BORING VAPOR a ❑DESTRUCTION: INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATION! A :❑ INDUSTRIAL ❑OPENSOFTGM DIA.OF WELL EXCAVATION ]-inch DIA.OF CONDUCTOR CAMNO NIA O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPV: N/A DIA.OF WELL CASING NIA D - ❑ PUBUCrMUNICHPAL ❑DRIVEN DEPTH OF GROUT SEAL N/A SPECIFB:ATKIN cement-bentonite R D IRIO RATION/AG ❑OTHER GROUT SEAL INSTALLED BY N/A GROW BRAND NAME N/A E O MOMTORNO; GROUT BEAL PUMPED: ®Y. ON. CONCRETEPEDESTALSYDRILLER:❑Y. ❑NN/A s APPROX.DFPTN multi1je bor1nPS 5-45 ft bgs LOCKING CHESTER SOX/STOVE PPE S PROPoAFD CONSTRUCTUNIDNWNG NUMB: MUD ROTARY AIR VOTARY AUGER CABLE OTHER HVdra_ ul1 C_Push 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.IBNALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTNACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES SNE FDILOWIOIQ: •I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-4 COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 34 HOW IN ADVANCE FOR ALL REQUIRED INSPE MNS A[I]O•I 4pi/pff, CCO�MPLETE DRAWING AT LOWER AREA PROVIDED. BIe^tlX THIS �s A . �1VOAv-cX V��hCLGO D.I. o L1 PLOT PLAN 10,.1.Scott.)B M. •to 1. NAMES OF STREETS OR TOADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PGRGM ED t. OUTLINE OF THE POPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, GETTYSBURG PLACE ' i3iiiiiii:i$ ii'i�''" S 'ii<Ei` •• 13 46 :;:c• t , 30 O •siiE a ® rYppp..d sou vPeP ;:;:;• :t RertRp Leealfon73 :; r•;• ::•: 72 �^• •::: ;::� .::: in •:•:•• I H 1 / DEPARTMENT USE ONLY 2] / App1l.Mbn Ave.lsd BY � OKe ✓r Y r� Aru Grein ImpealNn BY Da. Pump Imp.Uen By DMa Omlrwtlen Imp.lbn By OMa Cemmo-n.: ACCOUNTING ONLY: AID/ FACP PE CODES FEE INFO AMOUNT REMITTED CHECKORCASH RECEIVED BY DATE PERMIDSERVICE REQUEST NUMBER INVOICE *SDCDs Defined in the First Final Consent Decree Order, Judgement and Reference to PuDHBalth SSrv.-EnYirO.173(3/98) Special Ma r filed with the Court on January 18, E Section IV, Paragraph G.