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3 APPLICATION FOR WELLIPUMP PERMIT AN JOAOUIN COUNTY PUBLIC HEALTH SERVIC IO ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209( 466.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComploto in Tylplkote) APPLICATION IB HERE 8Y MAGE i0 THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY StoBLIC ckton O HEALTH BE Sheridan VIRaNMrox.HEALTH west of Gettysburg 374 Lincoln Center y, Pp arY PARCELe 200'r place inters ion JOB ADDraBeroR APNr (SDCDS)* 1900 Powe 1 t. t Floor SET OWNER-SHAME -/o Donald T. Bradshaw, Levine-Fricke-ReCOnAdWG6R Emervvillen CA 94608-1827 PHONE (510 652-45 ADDRESS UCr PHONE/ CONTRACTOR 950 Howe Roa CA-656407 510-313-5800 SUBCONTRACTOR Gregg In-Situ Inc. ADDRESS Martinez, CA 94553 _uC# PONE# TYPE OF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repelr PTH PUMP eET_—FT. FIRST WATER LEVEL O H.P. DE �y�-r PE OF PUMPI Y-1 SOIL BORING a RY ❑ OUT-OF RERVICE WELL ❑ GEOPHYSICAL WELL A ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONBTRUCl10NBPECIFlCATIONS ❑ INDUSTRIAL [I OPEN BOTTOM CIA.OF WELL EXCAVATION 7 hae DIA.OF CONDUCTOR CASINO NIA D TYPEOFCA81N0/BTEELRVC N/A DIA.OF WELL CASON) N/A D ❑ MIMESTICMDVATE ❑GRAVER PACKIRRE cement-bentonite DEPLN OF GROUT SEAL total depth SPECIFICATION A ❑ PUBLIdIONUAGL ❑DRIVEN N/A E ❑ IRRIGATroN/AG ®OTHER GROUT SEAL INSTALLED By contractor GROUT BRAND NAME ❑ MONITORING GMUTSFALFVMPED:MYr ❑N- CONCRETEPEDESTAL BVORIUAR:❑Yr ❑Ne 5 LOCKING CHESTER BOXIRTOVE PPE S APPROX.DEPTH 80 feet Hydraulic Push PROPOSED CONSiRUCTIOMmNWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEAEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TRE WORK WILL BE DONE m ACCORDANCE VNTN SAN JOAOUIN COUNTY OPDINANCEB.STATE LAWe,AND RULES AND REGULATIONS OF THE BAJOAQUIN COUNTYNOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIE8 THE FOLLOWING!'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NMICH N . THIS PERMIT IS ISSUED,I N JOA NOT EMPLOY PERSONS SUBJECT TO WORKMAN9 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: .1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB IBBUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TIRE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOMM INSM,IONS AT CIOIR 4494IS22. COMPLETE -DRAWING AT LOWER AREA PROVIDED. Do. BIFn� Oc�9�l. \ 1. TIOa PLOT PLAN Ith.1.Sed-I Sed- 1 inch.1. 80 fe t 4. LOCATION OF HOURE SEWAGE DISPOSAL SYSTEM OR PIOPOBED 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE GRIMBAL SYSTEMS. 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 3. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY On ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PAMS,DRIVEWAYS,AND WALKS. ww O o0 GD 0 4 y1Sin S = t LL �W2 ,V p 0,C) U U W0 O a a SHERIDAN WAY j U 60� Qw 'V K3 yy1 V1 OSS JI X00 wax a3 WWF CIAO LJj N I .... I�(aRilmltTd�)➢�L�.t and Reference to Special Master, filed with the *SDCDs Defined in the First Final Consent Decree q Court on January 18, 1996; Section IV, Paragraph G. Del- 2'ZS' 1 A•w AnPBeetian A..Ite Br GreU Impevlbn By Dns Pune lnepeetlen eY D-te Be. Cnmwtbn Imneerlen BY CemmsB-: 5 C Gv'c-v'a�whFrerti� 2�rri6t- R� 05l L. ACCOUNTING ONLY: AID# FACT PE CODFA FEE IMO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISEIIVICE REQUEST NUMBER INVOICE 0 55� 2'29. a( ► 3 Pub.Health Sam.-Enviro.173(3/96)