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1 Y PPLICATION FOR WELUPUMP PERMI SANWAOUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED ICompMle in TrIpReals) APPLICATION IB HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR ApH# 374 Lincoln Center CITY Stockton ppRCEL BIZEIAPN/Ben Holt Dr. Settling Dry eanT.ng a en ens s 1900 Pqwell St. 12th Flr. OWNER'BNAMEC/o Donald T- Bradshaw,. Levine-Fricke Recon Alm"EmerwTll, CA 94608-1827 mowA510-652-4500 CONTRACTOR AGGRESS "CO PHONE/ Gu$comm,TOR Gregg In-Situ, Inc. 950 yowe R8 A 94553 mg.A 656407 PHONE 410-313-5800 TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALLATION ElWELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J RVPE OF WMPI ❑N.0 Repel, N.P. DEPTH MMP SET FT. FIRST WATER LEVEL G ❑ OUT OF SERVICE WELL ❑ OEOMIYSICAt WELL/ Ak BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONATRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 7-1nCheS DIA.OF CONDUCTOR CASINO N/a O ❑ MMESTICSWVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/GTEELNVC N/a DIA.OF WELL CASINO N/A D ❑ PUBLICMVMCIRAL ❑DRIVEN DEPTH OF GROUT SEAL Total Depth SMCIFICATIONCement-Bentonite B ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Contractor GROW BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED:®Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne $ APPROX.DEPTH 80 feet LOCKING CHESTER BOX/STOVE RPE N/A S PROPOSED CONSTRUCTIONIdtlLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Hydraulic Push 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE UWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TARS PERMIT 18 ISSUED,1814ALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR Rule CONTRACTING SIGNATURE CERTIFIES TIE FOLLOWING: •I CEWIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOAR{IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT IMR 408J 22. COMPLETE DRAWING AT LOWER AREA PRGVIUEU. $10�T , TI.Site Project Manager o.r. not PUN lO,.n 1.SoY.I&.I. •r. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TIRE PODPERTY,OIVINO DIMENSIONS AND WHIN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .fl A1 •K� N� \ 1 " >m , 01 J__� _'_ __.+ �_._" I I 1 \>.,.i-L��K\•iK \a Ri\ \\ � w•'�.�d'"vi_�.,� � .. '�.9..-rx sem./� T\ ..,I 1^-1 1 11 � � �i\ V \ \ Y>" �_�� _` luua ma r;r>" w•-[� . I •� j'�_. ___.i� `�� --'I 4_ "oamy�� m\ I', /�.''q,i.�� .wo�p_v ` �-° � C1��.%p 1 I _-! c/-__ .J _�-9'i'i L \ �"A m-n .-(,�1�� ucax rlm,a,RF.[m �,�• l ` '^{ Ao.-FRF ,1 \ o,nA✓ t tP...r'•v \ � \�Rd' ./� � '• 1 I ever IA /'`' `\• \ \ \ ., ups ur ui.-F J�\ 51 1 C\. *SDCDs Defined in the First Final Consent Decree Order Judgement and Referenkd to Special Mastet Filed wii °kA@'ECb$Yt° January 18, 1996; Section IV, Paragraph G. nppnP.Gpp Ap..Pr.a By: /V�4�O7— oH. I,0�2�f •`l � n,.. OreU ImP.Gen By Dna Papp Inepee$en By Del. Deeln,ellen Imnenllen BY Dere DemmeMR 5� L Nbu-L P 12-15 9l ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED CNECK:IMASH RECEIVED BY DATE PEMITFIVIVICE REQUEST NUMBER INVOICE o $ 301 S 10.2 . D3 I Pub.Health Serv.-Enviro.173(1197)