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APPLICATION FOR WELUPUMP PET <br /> JOAQUIN COUNTY PUBLIC HEALTH�VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Com <br /> lamin <br /> km- <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WNII BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,FNUONMENTAL H ALTH IN Co . <br /> JOB ADDRESSMR APN/ 374 Lincoln Center <br /> Se Tag y ea n s e190Q—P Stocktons 1� AA - <br /> OWNER'BNAME c/o Donald T. Bradshaw, Leviae-Fricke-Reco aG,'e'TI'3 I (510 <br /> TMDDREee Emeryville, _CA 4608-1827 <br /> CONTRACTOR PHONE/ <br /> ADDRESS HCE <br /> SUBCONTRACTOR Gregg In-Situ PIONS/ <br /> Inc. owe ADDRESS Martinez, CA 94553 LS:02A lmoNE/- Do <br /> TYPE OF WEL MUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL/ <br /> ❑ INSTALLATION ❑WELL SYSTEM MPA1RH.P. 11OTHER <br /> ❑New <br /> ❑ CROSS-CONNECT REPAIR 1:1 VAPOR VAPOR EXTRACTION <br /> ❑RepNr J <br /> HYPE OF UM% DEPTH UMP eET__FT. FIRST WATER LEVEL <br /> ❑ OUT -SERVIOE WELL 11 GEOPHYSICAL WELL/ Rry O <br /> ❑OESTRUCTro W A <br /> L'l BOIL BORING <br /> B <br /> INTENbED UeE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM A <br /> ❑ OMESIIC/PRIVATE ❑GRAVEL PACK/SIZE DIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CABINO N/p <br /> TYPE OF CASINO/BTEEIIPVC D <br /> ❑ UBLICOAUNICIPAL 11 DRIVEN Depth <br /> DIA.OF WELL CASINO_ D <br /> DEPTH OFOOIIT SEAL_TOtal Depth❑ SPECIFICATION Cement-Bentonite ONITOIONG ❑OTHER GROUT SEAL INSTALLED BY Contractor OOR <br /> M <br /> ❑ MONITORING ITT BRAND NAME— E <br /> GROUT SEAL PUMPED: E Vee ❑Ne CONCRETE PEDESTAL BY DRILLEM❑Yr [IN. a <br /> APPROX.eEraN 80 feet <br /> LOCKING CHESTER BO%/STOVE RPE N/A <br /> PROPOSES CONt1IlUCTION/dbWNO METHOD: MLAO OTAgyS <br /> AIR ROTARY AUGER CABLE OTHER Hydraulic Push <br /> I HEREBY CERTIFY THAT I <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY,PREPARED O <br /> THIS APPLICATroN ANO TNAT THE WORK WILL BE NE IN ACCORDADE WITH BAN JOAOUIN COUNTY oOINANCES,STATE LAWS,AND PULES All <br /> TIIIB PERMIT IS ISSHOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOIK MRWHICN <br /> UED,I BIIALL DT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HINNO OR SUB CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING- •I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'SCOMPENSATIONINGSIGURE LAWS OF <br /> CANFORNIA.' THEA CANT MUST 24 HOUSE IN ADVANC/E�FOR ALL REQUIRED INSPECTIONS AT 12"1 4BBOA22. COMPLETE DRAWING AT LOWER AREA PROVIDE . <br /> R✓- rine_ Site Erojeet ManaZpr <br /> PLOT Da. � y <br /> 1. NAMES OF BTREETB OR MADS NEAMBT TO OR BOUNDING HE PROPERTY.N Ktr�to Basis •to <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND DRTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOGM <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPpSEO EXPANSION OF$MADE DISPOSAL SYSTEMS. <br /> STRUCTURES,IDIVDID COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, 8. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDGEO FIFTY FL <br /> ON THE PROPERTY OR ADJOINING PgPEgry. <br /> I_ <br /> \y \ I11 <br /> � rIf <br /> I• , <br /> 7LQLiR..\. <br /> t 1 <br /> 2'" - LL'_­_''_1.' <br /> _- 1 t <br /> t <br /> t <br /> s x I I u i <br /> ( I <br /> .....i' �... .._I �'—'. ...7II <br /> .......... <br /> I11 7 _ <br /> L I} , B a t o < ....t <br /> let 5 '(' ,\ 1�' `-.• 8 e <br /> ,. g <br /> $Y <br /> enc `1 �', I st'``a° °a1R�is� a ..u, ,x <br /> ,I <br /> E , I <br /> �MIMENT <br /> USE ORCr moi/ �1c <br /> Appllaetlan MoePIM By. � DNS_ / / / / AI— <br /> Gra.A IrnPxtbn er Dele <br /> Pune Inepmtlen By Dete <br /> Deelndbn Inpeatlea BY <br /> Dete <br /> Garr:mn,H: G.'I''l o.F- 5{ac.�to,r-� �L✓Y_✓o4c-(�LL•x.a.I�Lt �e✓rvtt-I (0�'132(o cx�lo 19`x" <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INTO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMITISERVICE REQUEST Nm@IA INVOICE <br /> '7.1 o 13to <br /> .HeaRh Sew.-Enviro.173(1/97) <br />