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4 1 A PPLICATION FOR WELL/PUMP PERMIT SA AQUIN COUNTY PUBLIC HEALTH SE ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IcempA1@ In 7E1pIkuEl APPLICATION IB HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN MAGIAN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH BERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSMH AM# 374 Lincoln Center GIT- Stockton PARCEL BILE/APJ# N. Pershing Pl Sett Tng Dry Cleaning Detenaents s 190 ., . OWNER'S NAMEC[O Donald T. Bradshaw Levine-Fricke-Recon ADDRESS Emeryville, .CA 94608-1827 PHONE*510-652-4500 CONTRACTOR ADDRESS UG# PIONS# ava coNTRAttoR Gregg In-Situ, Inc 950 Howe Rd ADDnESdartinez, CA 94553 LJC#CA-656407 PHONE#510-313-5800 TVPEOF WELLTUMP: ❑ NEW WELL ❑ REPACEMEW WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# [JNeva❑Rep.I, HP. DEPTH PUMP SET—FT. FIRST WATER LEVEL p RVP OF PVMPI ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL# ® SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2-inches DIA,OF CONDUCTOR CASING N/A D ❑ DOMESTICI VATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC N/A DIA.OF WELL CASING N P' D ❑ PJBUCWUNICIPAL 11 DRIVEN DEWII OF OROUT SEAL Total Depth SPECIFICATION Cement- Bentonite R ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY RO Y Contractor GUT BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED:0Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑N. S APPROX.DEPTH 80 feet LOCKING CHESTER BOX/STOVE PPE NSA S PROPOSED CONOTRUCTIONRASWNG METHOD: MUD ROTARY AIR ROTARY I AUGER CABLE OTHER Hydraulic Push I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS KAMM IS ISSUED,I SHAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ,1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN@ATION"We OF CALIFORNIA' APPLICANT MUST CALL 34 HOUR@ IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IMN 4604D411. COMPLETE GRANTING AT LOWER AREA PROVIDED. Slp�X O '�--�� Q, _ T101 Site Project Manager o.le �G PLOT PLAN ID,.w 1.Sed.(Sada •1e I. NAMES OF STREETS OR ROAM NEAREST TO OR BOUNDING THE PROMITTY. 4. LOCATKIN OF HOUSE SEWAGE DISPOSAL SYSTEM On P omsEO 2. OUTLINE OF THE PIOPRTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 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 PROPmTY. l 1 > \ NMIC 1 i o, r � 1 . . 1 I ..._I r I \ •'\ \�\J{�1\ \ \ __. ) -p .. �O \ CP-219 j MW- i 1. , h_. . �__ \ •. , \� 0.J Yor-fil 4 AA ate. - ..._ti 1__...-. 1 I. _ � 1 � \ \ \SEJ� - `I i \D m/p/E"• i \ Y 1 I • ._I .___� I 11 \ \ nx\ \\ ..1d'owx'LY_, , ..- ex'r/ \} I \ 41 _ i � J• r \ C i \ J A. ®1\ �L•d� �C\� \`i �KI wmx rawrrn.Lm �/' �\\ ....-, _._'' X11-.-_ - (`� \ \ \ j'• .:\ � \ ,� �'•@fi ,I' 1�.' . \' `\ Y ; *SDCDs Defined in the First Final Consent Decree Order Judgement and Referenced to Special Master Filed with t Court on Jan ua y 18, 1996; Secti BL�P�MaFVgh G. Appucetlen Ae. IM IH 1 �/ D.t. Go•�� `� Ar.. G'.0 In<p,wllen Br t D.xa P1 p InppmtIon By DN. De.mKGe,.Imneeaon Br D.t. Ge,nmw•1.:��R �cn L�ocLc.y\.✓r •fi 2Yrn.l i 3_ 3$Z-LV "12 12•l5 ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PEAMITISERVICE REQUEST NUMBER INVOICE 0 3018 101 . El4DO, Pub.Health SeP.-Enviro.173(1/97)