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A' PPLICATION FOR WELUPUMP PERM HW SAAOUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplot• In Triplketel APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOOS(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ^/Q JOB AODRESSMR APNI 374 Lincoln Center CIT, Stockton PARCEL SIZEIAPN/ 077- L// -( / Settling Dry Gleaning e e s 1900 F UWet t 8 L., . OWNER'SNAME_c/o Donald T. Bradshaw, Lev ine-Fricke-ReconADoRESS Emeryville, CA 94608-1827 PHONE/ 510-652-4500 CONTRACTOR n�� T ADDRESS OltN PHONE/ SUB CONTMCTOR,nii TC rrQ(rJ4,yNll'w0 ADDRESS'P/re n,...L TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOIST GRIND WELL/ 450�- OTHER ❑ INSTALLATION ❑ WELL BYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑Naw❑nepelr N P. DEPTH PUMP BETFT. FIRST WATER LEVEL O R Yet OF PUMPI s1 ❑ OUT OF SERVICE WELL 11GEOPIYSICAL WELL/ L1 SOIL BORING S Ld DESTRUCTION: MW-21 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j 1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING NONQ D ❑ DOMESTICIPFt VATE ❑GRAVEL PACK/SIZE TYPEOFCASING/NTEELIPVC5" ST— DIA,OF WELL CASINO SII D ❑ PUBLICIMUNICIPAL El DRIVEN DEPTH OF BMW SEAL ~IAO SPECIFICATION —' R ❑ IRRIGATION/AO 13 OTHER GROUT SEAL INSTALLED BY CwTITACT&L GROUT BRAND NAME VrYKEiIPI" E ❑ MONITORING BMW SEAL PUMPED: ❑Y. ❑N. CONCRETE PEDESTAL BY DRILLER:qY- ❑N. S APRIOX.DEPTH I S U( LOCKING CHESTER BOX/STOVE PIPE �/ 5 PROPONENT CONST"WINNABSWNG METHOD: MUD ROTARY ]� AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT�THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REOULATIONS OF THE SAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-- THE APPLICANT MUST CALL 24 HOURII IN ADVANCE FOR ALL REOURED INSPECTION•AT INMI 4011 A23. COMPLETE DRAWING AT LOWER AREA PROVIDED. 6101 X nna Site Project Manager D.0 PLOT PLAN in'.w la Sa.l.r BR.1• •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,DIVING DIMENSIONS AND NOIR"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.DRIVEWAY A wove \ \ - U-1 / oa V) . o / � 5 0LLj \ a3a� o \V J W LJ A *SDCDs Definedin the First Final Consent Decreed�u��g�e��gg Secon�YReferenced to special Master Filed with the Court-on January 18, 1996; Section`Y�,'•'I'aragrap7L G. APPne.Ien A.RRPI.d Br�/� ,✓L� Dw -L'-['• / A... Oraul lmpaaObn Sr am. P. p ln.PaaORn ey Dxa Gmnuellen Imn.aean er Dau Dammam.: Lir<w(n roper Iles guess � c�a+ciJ !o'20.9�- ACCOUNTING ONLY: AID/ FAD/ PE CODES FEE INFO AMOUNT REMITTED CNECKAICAS" RECEIVED NY DATE PERMITISERVICE REQM--- Pub. 02 0 3013 IVB ro.Zq. 0 Health Sew.-Enviro.173(1/97)