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APPLICATION FOR WELLIPUMP PERMIT AN JOAOUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE,STOCKTON. CA 95201388 (209) 499.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IcampMlB In Trlplknlnl APPLICATION IS HERE BY MADE TO THE SAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE M14 SAN JOADUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.x Benjamin J. Holt Dr. approx 200' W of Gettysburg 374 Lincoln Center clr+ Stockton PARCEL SRE/APNI P1a Tn rs tion. JOB ADDRESS/O�.APH SD s owe t. t Floor J ,1„1L Book 097-43 OWNER-SNAMEv/o nnnald T Rradaham+e Levine-FrirkP-Rpnn ADPWP F_mP ,iry-•11e�CA 24608-1827PNINE E�510)652-4500 r CONTRACTOR ADDRESS nu Imwe UK# PHONE, OUR CONTRACTOR r�Oy In—SiLU, Tnr - ADDnpAe Martinez CA 94553 H ,CA-656407c„oNE,510-313-5800 TYPE OF WELLPUMP: ❑ NEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL, ❑N.11 nm.1, N.P. DEPTH PUMP SET_FT. ,,}}FIRST WATER LEVEL OVT-0PBERVK:E WELL ❑ O (TYPE OF PUMPI GEOFHVSICAL WELL, 13 BOIL BORING R ❑ ❑DESTRUCTION: A INTENDED UAE TYPE OF WELL CONSTRUCTION SPECIFICATION{ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OFWELLEXCAVATION 2-inches_ DIA.OF CONDUCTOR CASINO N/A D ❑ DOMESTICIPIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELPVC N/A OIA.OFWELICASINO N/AR Tota ept cemen >_- en one N ❑ PUBLICI.IUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION❑ IRRIGATIONIAO OTHER OROUT SEAL INSTALLED SY_,,O11CLiiCCO1: OROUT BRAND NAME _aj�4 E [IMONITORING GROUT SEAL PIMPED: My.EDY. ❑N. CONCRETEPEDESTALSYDRILLER:❑Yr ❑N. S APImOK.OPTH R(1 fPPt LOCKING CHESTED BOXMOVE PPE N/A R PROPOSM C0Wn,, rO,,NLLENO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEfl Hydraulic POST] I HERIRBV CERTIFY THAT 1 NAVE PREPARED THIS APPl1CATION ANO THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND MR 9 AND PEOULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CEITTIFV THAT IN THE PERFORMANCE OF THE WORK WR WHMH THIS PERMIT IS ISSUED,ISI/ALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR OURCONTRACTINGSIGNATURE CEROFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS FERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUBT CALL S,HOURS IN ADVANCE FOR ALL REQUIRED INSMMNB T MOB)44941432. COMPLETE DRAWING AT LOWER AREA PROVIDED. 611m X�� 5.�. �.�� -�_ nn. G•4”' u,�e-.re Nert�m. D.I. .a 8\y PLOT PUN ID1.w 1.B.0.1 ee.l.1 inch•ue 80 feet 1. NAMES OF STREETS On ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM GR PWI`DAED E. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION N F SEWAGE THIN AAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS ADJOINING IPG PR OF GINE HUNDRED FIFTY FT. WnuctVOES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING FFOIERTY. Q Oa 1 r w N ��w W r 0 W WWF V 4 ONS A W 4 O OA V J W f U a BENJAMIN J. HOLT DRIVE E-I H W W Y�A DY ��S QQw WOO OW6 K3 NO Uj *SD CDs Defined in the First Final Consent Decreeand Reference to Special Master, filed with the Court on January 18 96; Section Iv, Paragraph C. try q� D.R. ZUJ APWleglen A..splad By O,aN Impeelbn By D.,. Pump ImpseOen BY D.la D.K. Ommdbn ImpwO.n BY � ,-I Opn,msl.: S�C.�nc.r�4chn�T 2VnM,�- �� G-I— ACCOUNTING ONLY: AID, FACT PE CODER FEE INFO MOUNT REMITTED CNECKOMASH RECEIVED BY DATE PBEWTRERVICE REGUEBT NUMBER INVOICE 55� x'28• D 3 Pub.Health Sem-EnWo.173(3/96)