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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388,304 EAST WEBER AVENUE, STOCKTON.CA 95201388 (209) 463.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TrlpOeote) APPLICATION IS HERE BY MADE TO THE BAN MAGIAN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIRE APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 8-1115.3 AND THE BTANDAROB OF SAN JOAQUIN COUNTY PUBLIC HEALT14 SERVICES,ENVIRONMENTAL HEAL,N MB O JOB AODRE89/OR APN, 374 Lincoln Center Stockton Stanton Way, approx, 100 [� o Gettysburg Cme PARCEL BREIAPNF Place intersectior SETTING DRyy CLEA[�ING DEF s Powell t. th oor OWNER'SNAME c o onald T. Bra shaw, Levine-Fricke-RecorAolWres Emeryville, CA 94608-1827 PHONE, (510)652-4500 CONTRACTOR ADDRESS IHC, RHONE, 950 Inc. SUBCONTRACTOR Gregg In-Situ, owe oCA 94553—ADDRESS uc,CA-656407PtoNE,510-313-5801 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑nep.1, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI FY, ❑ ow-or-SERVICE WELL ❑ GEOPHYSICAL WELL, K9 SOIL ROBINS B ❑DESTNIICTION: INTENDED use TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 9-inrhnc DIA.OF CONDUCTOR CASINO N/A O ❑ DOMESTICA'RIVATE ❑GRAVEL PACKMIZE TYPE OF CASINORHEELRNC N/A DIA.OF WELL CASINO N/A D ❑ RIBUCARR ICIPAL ❑��]DRIVEN DEPTH OF GROUT SEAL total depth SPECIFICATION cement - bentonite R ❑ IRBIE3 GATIONIAG 0THER GROUT REAL INSTALLEDyBnV contractor OROVT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED:PJYoo []No CONCRETE PEDESTAL BV DRILLER:❑Vee (IN. 5 APPROX.DEPTH 80 feet LOCKING CHESTER wxmoVE RPE N/A 5 PROPOSED CONSTRUCTION/deLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE GONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND,VIES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEWOHMANCE OF THE MW FOR WHICH THIS PERMIT IB ISSUED,1014ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IN ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CAM 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT CtOO14Y3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. BIPr.d X�Qv-��+1. l.� _) ntl. \ J`�OPAaC ./ Dns inch- ee POT PLAN to,.w to 6er.1 San. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROHmaw 2. OUTLINE OF THE MPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOBED S. LOCATION OF WELLS WITHIN RADIUM OF ONE HUNDRED FIFTY P. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WARNS. ON THE PROPERTY OR ADJOINING PROPERTY. 6 w S4aw O W YSWSV U C, O 2 mOwl0 O m�w g $ 00 E STANTON WAY I � ® U a a u o;� wa3 Fy C4 QMrcE-I 3 w h x a o w N J ..... ,.... .__ _........ ._..... _.. ... .:._......... ........... SD s Define Tn t e First ina nsent vecree Urcler, Judgement and Reference to SpecT.a as er i e Court on January 118, 1996;9.� ,.Section IV, Paragraph WARTMENT USE ONLY APPI�a.Han A.eept.H RIO /V I /Y LK.L.!-�KJ On. L•�U• / A,.. tj G,oa b.peelbn BY D.,. Papp Hn.paatlan BY D.I. UeoV,ntlen IwpaaHon BY On. Dainmem.: `L7�G &C.roc�.hn�,vl.-t &ngr� ACCOUNTING ONLY: AID, FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK,ICASH RECEIVED BY DATE PERMITISDRVICE REQUEST NUMBER INVOICE 2�0► �5g 2 . of (-7-3D Pub.Health Sew.-Enviro.173(3/96)