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APPLICATION FOR WELLIPUMP PERMIT �r .SAN JOAQUIN COUNTY PUBLIC HEALTH SERVO ENVIRONMENTAL HEALTH DIVISION P•O. BOX 3K 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 498.3410 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER (CBmpkis In TrlpRetlB) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.TIRE APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE BTANDARD8 OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERMCEB,ENVIRONMENTAL HEALTH DMBION. JOBADORESSMRAPN2 374 Lincoln Center Stockton McClellan Way approx. 2001 west of Gettysburg SET s clri PARCELSIZUAPN.Place intersection OWNER'SNAME c/o Donald T. Bradshaw, Levine-Fricke-RecopsorTE9f)• IWOvvillel CA• 94608-1827 PHONE,x (510)652-4500 CONTRACTOR ADDRESS UCP PHONE F a SUBCONTRACTOR Gree In-Situ, Inc. ADDREBBMartineZ, CA 94553 uc2CA-656407,„,,,,510-313-580 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F ❑ OTHER ❑ INSTALLATION 13WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL F HYPE OF PVMPI 11 N.1:1nw.11 N.P. DEPTH RUMP SET—_FT. FIRST WATER LEVEL , ❑ fVVtt ow,or sERVIOE WELL 1:1GEORIYBICAL WELL B H% BOIL BORING B 11 DESTRUCTION: INTENDED USE TYPE OF WUl CONSTRUCTION SPECIFICATIONS — A 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 9—in,hes DIA.OF CONDUCTOR CASINGN/A D ❑ DOMESTIC"VATE ❑GRAVEL PACK/BRE TYPE OF CASINO/STEINJrW N/A DIA.OF WELL CASING N/A D 11 RUBUC/MUNICIPAL 11 DRIVEN DEPTH OF GROW SEAL total depth SPECIFICATION cement-bent— onite R ❑ IMIGAMONITTRINO THER GROIN SEAL INSTALLEDVvBTTY contractor GROUT BRAND NAME N/A E ❑ MONITORING BMW SEAL PUMPED:MY. [IN. CONCRETEMMSTALSYDRILLER:❑Y� ❑Ne S APPRO%.OFDTN 8O feet LOCKING CHESTER BOX/STOVE RPE N/A S PROPOSED CONSTRUCTION DAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERNVdraUHC Puxh I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IB ISSUED,I0IAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S mRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PEDSONS SUBJECT TO WORKMAN'/COMPENBATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 IIOIAIS IN ADVANCE FOR ALL BEGGARED INSPECTIONS AT 1"914p.`1E22, COMPLETE DRAWING AT LOWER AREA PROVIDED. SISMd � 1 inch 80 et ROT PLAN IDIew le SeYal Bels Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPETITV. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DHIMSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND 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. K y a dl w Gd <o w W yWV 4 W B W U QwM ly TWO U1 C r UWU �OJW V 'w Q 0 b 1.7 McCLELLAN WAY Ln -- Ln VZA H H o a 9pw <w U 88C3� yW VI wom �Wo OW UN J 1 s eine Tn t e Trst na onsent 1jecree Urder, u gmen an a ere ce , Court on January 18, 1191966;; Section IV, Paragraph WARTMEI T USE ONLY en APPKeMAv tM BY '}'.L �i i��11 / D.I._ Li'/�G/• / / M.. O.IA BKP.eSo,BY DTI. Pvnv ImP«Sen BY 0.,. Oeetnnllen Impeetbn BY Co. D.mmer,l.: SSG znu^oac,l•Lmand el'IVILt q�'- D5�-LV �Db l I bD�7 ACCOUNTING ONLY: AIRF FAC! PE CODES FEE INFO AMOUNT REMITTED CHECIONCABN BECBVFD BY DATE PFRMITISFAVICE REGUEBi NUMBER INVOICE 220 55 2_Yjj v I 2 Pub.Health Serv.•Enviro.173(3/96)