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APPLICATION FOR WELLIPUMP PERMIT j SAN JOADUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, TA EAST WEBER AVENUE,STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comploto In TEIPReote) APPLICATION IS HERE BY MADE TO THE SAN"AMIN COUNTY FOR A PERMIT TO CONSTRUCT ANURR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 5-1115.3 AND THE STANDARDS OF SAN JOAUUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Stockton Seward Way, approx. 2001 west of Gettysburg JORADOWSS/ORAPLIl374 Lincoln Center DITY RD4 (197„ PARCEL eavAPNI Place intersection. SETTLING DRY CL s 1900'POWtTll -LZT4 OWNER'SNAME n1n nnnnld T R ^dchnw TPvine-Fricke-ReconARlmuce Emeryville. CA 94608-1827 PHONE! (510)652-4500 CONTRACTOR ADDRESS 950 Rowe Rua LIO! PHONE! SUBCONTRACTOR Gregg In-Situ, Inc. ADDPEseMartinez, CA 94553 UcPCA-656407PHoNE#510-313-5800 TYPE OF WELLFUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J ❑New❑moll, H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 (I YPE OF PUMPI ❑ OVT-orSERVME WELL ❑ GEORIVSRAL WELL I ® SOIL BORING B ❑DESTRUCTIONS INTENDED USE TYPE OP WELL CON8TRUCTION BPECIFICAI10N6 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2-inches GIA.OF CONDUCTOR CASINO NA O ❑ DOMESTICB'RIVATE ❑OMVEL PACK/SIZE TYPE OF CASINO/BTEEUVVC NIA VIA.OF WELL CASING w'x* D ❑ PUBUC/MUMCWAL ❑e�DRIVEN DEPTH OF GROUT SEAL total depth SPECIFICATION cement-bentonite A ❑ IRRIGATION/AO MOTHER GROUP SEAL INSTALUMe BY contractor GROUT BRAND NAME N/A E El MONITORING GROUT SEAL RIMPEO:LJ Yr ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yr Elm S APPROX.DEPTH 80 f eet LOCKING CHESTER BOX/STOVE RPE-�-A_ S PROPOSED CONSTRVCTIONIMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push I HERI:BY CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAMIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER On LICENSED AGEM'S SIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOR'9 HIRING OR W"ONTRACTIN0 61ONATUM CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF CALIFORNIA: THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL MOLL E,INSPECTIONS AT 120814084IN42S. COMPLETE DRAWING AT LOWER AREA PROVIDED. 'IPnea 1 inch 8 feet ROT PMN ROPE m BONaI Bede 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF NOVSF SEWAGE DISPOSAL SYSTEM OR RIOIIOBED 2. OUTLINE OF THE PROPERTY.OWING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF$MADE DISPOSAL SYSTEMS. O. DIMENSIONED ODTUNF.B AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 2 ]M{[E 0 , y1JR O a — V1 SEWARD WAY - 00 JSN DSK aaw wrc3 ool- 6,C) Uw :......:.... _: ...:... .i. .. ..... ....._:... *SDCDs Defined in the First Final Consent Decree Order, Judgment and Reterence to pecLa as er, e Court on January 18, 1996`-1 section IV, Paragraph"SP,ARTMENT USE ONLY R /��/ APPIIeHIen Aeeeoled BY /74;A � DSU `' L Mr G.em ImoeeRlm Br D.R. PvnO mePeenen er Dae oe.I..NBen In.mm�en er D.I. GemmP,,.: SSG � oarhn�.ot�l.� SORA-�� aLy sob : 11r) ACCOUNTING ONLY: MDF FAC! PE COO" FEE INFO MOUNT REMITTED CHECKIPMASH RECEIVED BY DATE PORMIT/SERVICE MODEST NUMBER INVOICE sa 2.2s. 11231 Pub.Health SON.-Enviro.173(3/96)