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APPLICATION FOR WELLIPUMP PERMIT •SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICP ENVIRONMENTAL HEALTH DIVISION ]LlL P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201386 (209( 468.3420 NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (romp11I1 in Triplkltl) APPLICATION 19 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 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/474 i.t nrnln nter_ CTI Stockton Calhoun Way, app Poxx. 11001 west^ofTGettysburg Settling ury l,leB:nIT r en an s DGD-s'J� on OWNEWO NAME r/n T)nnnld T. Rradchaw Levine-Fricke-Recowciom. Emeryville, CA 94608-1827 -,N,400k097p34 CONTRACTOR `TErf657--45M- ADDRESS 950 No e Ruud VCA PHONE SUBCONTRACTOn Gregg In-Situ, Inc. ADDRESS Martinez, CA 94553 miCA-656407PNoNE510-313-580C TYPE OF WELLIPUMP; ❑ NEW WELL ❑ REPACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CH09&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S J HYPE OF PIMPS ❑N.11 Rep., H.P. DEPTH PUMP SET_". FIRST WATER LEVEL O ❑ ow-orSERVICE WELL ❑ GEOPHYSICAL WELL F 10 SOIL BORINGR ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION IpECIFICAT10N1 A 11 INDUSTRIAL ❑OPNBOTTOM DIA.OF WELL EXCAVATION 2-inches DIA.OFCONDUCTORCASING N/A O ❑ DOMESTICI RIVATE ❑GRAVEL PACK/91ZE TYPE OF CASINO/9TEELPVC NIA DIA.OF WELL CAMNG N/A ❑ moucMUNICIPAL 1:1 DRIVEN O a O rF�n DEPTH OF GROUT SEAL SPECIFICATION cement- bentonite I ❑ IRRIGATION/AG IXOTHER GROUT SEAL INSTALLED��EFBTLV rnvtrartnr GROUTBRANDNAME N/A E ❑ MONITORING GROUT SEAL PUMPED:fly. ❑N. CONCRETE PEDESTAL BV ORLLER:❑Yw ❑Ha S APPROX.DFPTH SO feet LOCKING CHESTER Box/STOVE PPE N/A a PLOPOSED CONSTRUCTIONIDRILLINO METHOD: MUD WTAI Y AIR ROTARY AUGER CABLE OTHER QJ;rl,,l r1 i r- Push I NENESY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION ANO THAT THE WORC WILL BE DONE IN ACCORDANCE WITH SAN NAWIN COUNTY ORDINANCES,STATE LAWS,AND ROLE$AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERrORMANCE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR BOB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORL FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TNM APPLICANT MUST CALL 24 MORE IN ADVANCE FOR ALL REOURW PROMOTIONSATIMEI 4q-t1PRR 23. COMPLETE DRAWING AT LOWER AA FRONDED. wcm x Z�=1' .7't'!. o-� nn. S.L�L �1 to A �c� D.1. POT PLAN IN.. 1.B.N.I&.1. 1 inch,t. 80'feet V 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 1. LOCATION OF NOOSE SEWAGE DISPoBAI SYSTEM OR PI01'O$ED 1. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL$WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY. w � Cn a s 4 y2 w CC[� U_ 4 G w W o� w of w 0,C)w O CALHOUN WAY7 Q JJ U a ova0 v �3� y J 29W w'C) V YWVI ry� Saw owe V pw U VI l► W V r NuCt _....i..... .. .. ......... ....... ..... ...:.......:..... s e ne n Me r , e erence o pecLa s , with the Court onnuary 18, 19961 Section IV,PBf'%},R>FV�ifF tPE ONLY ApPll.Ilan Avaep,ad BYJ D.,._ Or.0 Imv..,len BY Das Pune Impep,len BY OH. Oe.,nellan ImP.a1m�By D.,. U CemmN$.: S C- /11!rO�Et`nYP�E-�I I PPV7lY�I.T za GIS-- (75C L ACCOUNTING ONLY: AID$ FAQ# PE Coon FEE INFO AMOUNT REMITTED CHEDKF/CASH REDENED SY DATE PERMITIIFRVICE REQUEST NUMBER INVOICE a•2( Pub.Health SEN.-Enviro.173(3/96)