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APPLICATION FOR WELLIPUMP PERMIT • . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION R0, BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Trlpllewl APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOADUIN COUNTY DEVELOPMENT TFILE,CHAPTER 9-1115.3 AND TIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIIMSION. JOSADDITESBMn APNI 374 Lincoln Center cwv Stockton PARCEL SIZE/APN11�97-41-79 SETTLING DRY CLINING DEFENDANTS SDCDs pv� 1900 Powell Streetz Floor 12 OWNER'S NAME.0/O ➢Ona1d T. RYadShdw Levine-Fri Emer;millc .CA 94611R-1897 MONEF511-6n�500 COMPACTOR - AMM'9 UCI PHONE I BUSCOMRACTOR_.Transglobal Environmental Geochemistry11350 Monier Park Place ADDRESS Rancho Cordova,CA 95742 uc1706568 PHONE E916-853-8010 TYPE OF WEUVTUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR MMCTKIN WELL I J ❑ RIPE OF MMPI N. Repslr H.P. DEPTH PIMP BET FT. FIRST WATER LEVEL G ❑ OUT Of SERVICE WELL ❑ GEOPHYSICAL WELL A U SOIL BOSINGVAPOR s ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION ePECIFICATIONe A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 1-inch DIA.OF CONDUCTORCASING N/A D ❑ DOMEBTM/PNVATE ❑OMVEL PACK/SIZE TYPE OF CASINGISTEFt VC N/A DIA.or Vall CASING N/A D ❑ MBLICIMUNICIPAt 11 DRIVEN OEM"OF GROW BEAL N/A SPECIFICATION cement-bentonite ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY N/A GROW BRAND NAME N/A �1 E ❑ R ❑ MONITONO GROUT SEAL PUMPED:13 Yr Ne CONCRETEFEDESTALBYDRR LLE ❑Y. ❑NN/A 5 APPROX.OEPTN MULTIPLE BORINGS 5-45 FT BGS LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONS"WrONIDRWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERRvdraulic Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I BIIALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR OURCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS MMR IS ISSUED,I SHALL EMPLOY PERSON8 SUBJECT TO WORKMAN'S COMM$AnON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURAI IN ADVANCE FOR ALL REQUIRED INSPECTLONS AT I200I4084422. COMPLETE DRAWING AT LOWER AREA PROVIDED. elvmd x nv. PINT PAN IGrav Ie eoJel Setle 'to t. NAMES OF STREETSHFTI OR ROADS NEAREST TO OR BOUNDING THE DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PbPUSED 2. OUTLINE OF THE PROPERTY,GIVING ION OF AND NORTN DIRECTION. EXPANSION OF SEWAGE DISPOSAL 8YBTEMS. 3.STRUCTURES, OWLINNG AND LOCATION OF ALL EXISTING PATG AND PROPOSED 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. BTRVCTVREB,INCLUDING COVERED AREAE SUCH AB PA7108,ORVEWAVB,AND Wgll(8. ON THE PROPERTY OR ADJOINING MOPERTY. GST7.YSBURC PLMC6 a�.w:.• 13 67 • 51-• ••• ,' '• •'•' ® Proposed Soit Vapor Boring Location .�. 6 .� ... :; •::} � Paxet of Interest Z •:.;�; �; 0 flb 250 .;.•• r t • Z:;;;}};i: 0. San Jaaga/n . O :•:•: :•._: : Ceuary bP 'r rap soot aPapr ... .....� 73 92 ® •'••.•.•. . s • Iq . ::,�,: OO :�:�::• LINCOLN SCBOOL 79 74 DEPARTMENT USE ONLY AepM•Ibn Aeeapled BI• '� "�/ DN•,,,( It.a,:k M•• Oreul Impeclbn BY DNe gwne Inmxr(Inn RY DN• DeeUr=Ibn Imnevlbn BY ON• CemmeMc ACCOUNTING ONLY: AIDS FAC! PE CODES FEE INFO AMOUNTEM _RITTED CHECKIMASH RCEVED SY DATE PERMIT/SERVICE REDVEBT NUMBER INVOICE C , £- 1 ` ' L *SDCDs Defined in the First Final Consent Decree Order, Judgement and Reference to Pub.Health Sew.-Enviro.173(3/96) Special M er filed with the Court on January 18,.96; Section IV, Paragraph G.