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AAPPLICATION FOR WELLIPUMP PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 904 EAST VVEBER AVENUE, STOCKTON, CA 95201388 I2D9I 4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripRontel APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOnE98ron APNE 374 Lincoln Center CmYStockton Emeryn approx. l0o'P orflth2of Lincoolu.Rd. `nter- Sett settling Try eamng e en Book 081-13 OWNER'SNAME c/o Donald T. Bradshaw,Levine-Fricke-Rec,CA... Emeryville, CA 94608-1827 RHINE S CONTMCTOR ADDRESS LIC/ BONE E RUB CONTRACTOR Gregg In-Situ, Inc. owe ADwLEea Martinez, CA 94553 DCPA-656407 EmmF510-313-5800 TYPE OF MUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLS J IF YM OF WMPI El N. Roo.I, N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL G ❑ GDT-OPSERVICE WELL ❑ GEOPHYSICAL WELL I Iq ROIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CASINO N/A D ❑ DOMESTMI'GIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC N/A GIA.OF WELL CASING N/A D ❑ PUBLICNUNICIPAL 1:1 DRIVEN DEWHOFGROUTSEAL total depth SPECIFICATION cement-bentonite R ❑ IMIGATIONIAO ®OTHER GROUT SEAL INSTALLEDBYcontractor GROUT BRAND NAME E 11NI MOTORING BOUT SEAL PUMPED: MY. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne S APPROX.DEPTH 80 feet LOCKING CHESTEn BOX/STOVE RPE N/A S PROPOSED CONSTRUCT1ONAPRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER hydraulic Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Of DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COMMCTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWHIO: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA.- THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INgECT10NS AT IMI 440+1422. COMPLETE DRAWING AT LOWER AREA PROVIDED. nn. -5�e �*O L 2.1t- J"X' m,11 LT Mot PUN ID,.w to RP.Ie1 Belle 1 inch-to 80 feet 1. NAMES OF RTPEETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM On R10PDMD 2. GMUNE OF THE PROPERTY,OIVINO DIMENSIONS AND NORtH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED R. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY. 0 O 'D n O -0 N 0 0 ...... 0 LINCOLN ROAD _ O N E o A y *SDCDs Defined in the First Final Consent Decree Order, u gmen an e c with the � /lM Court on Jan ry 18, 1996; SectiRIFAI r`1"aa"Phh h G. •/�� APPIIC.ean Ae<.ete l By �Y In 4g,4 D.1._ (X 222 A,.. Grein lmeeelbn BY Dae Pme Imeptlen Ry Dae Doe"Ve leO Imeootbn By D.I. Den,n,a,,.: Cl� o F -(a L I Z� O — �v�roac.hv�L-e�d �✓rVl L ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO AMOUNT REMITTED CHECK IMASH RECEIVED SY DATE PIDWI TISEAVICE REQUEST NUMBER INVOICE 2 D 1 3 Pub.Heath Se v.-Enviro.173(3/96)