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APPLICATION FOR WELL/PUMP PET JOAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TFIpRente) APPLICATION IB HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE MH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVI�ENTAD(ALTH OMSIION. JOB ADDRESSOR APNI 4 Lincoln Center CITY Stockton PA IZE/APNe""V Betltlin Dry C1 an nK Defendants SDCDs * 510)652-4500 OWNERS NAME_ DD a1d Tra�ds Flaw, Levine-Fr>_cke- ecogDD,Eee Emeryville, CA 94608-1827 IOD F CONTRACTOR ADDRESS LICE PLONEI SUBCONTRACTOR Gregg In-Situ Inc. ADDRESS L�a�t nez, A 94553 LICE CA-656407 ( aQ�913-5800 TYPE OF WELL/PIIMP: ❑ NFW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECTREPAIR ❑ VAPOR EXTRACTION WEUL# J ❑N.❑R-0 H.P. DEPTH PUMP BET_". FIRST WATER LEVEL 0 RYPE OF PIMP( ❑ OVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ® BOIL BONNO S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONeiRULl10N SPELIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 2-inches DIA.OF CONDUCTOR CASING N/A 0 ❑ DOMEGTICIPRIVATE ❑ORAVEL PACK/BRE TYPE OF CAGING/STEEUPVC N/A DIA.OF WELL CASINO NA D ❑ WBLICIMUNICIPAL ❑]DRIVEN DEPTHOFGROUTGEAL Total Depth SPECIFICATION Cement-Bentonite R r ❑ IRRIGATIONIAG W OTHER GROUT SEAL INSTALLED BY Contractor GROUT BRAND NAME N/A E 11 MONITORING GROUT SEAL PIMPED: 13 Y. [IN. CONCREiEPEDESTALBYDRILLER:❑Y. [IN. 5 APPIOX,DEPTH BO feet LOCKING CHESTER BOXMITOVE PPE N A 5 Hydraulic Push PROPOBED CONSiIRUCTONNRIlUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULED AND REGULATIONS OF THE DAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEMIFIES THE FOLLOWING:•R CERTIFY THAT IN THE PEWORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB IRGUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUD CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• THE CANT MUSj,0AU.24 NOUNS IN ADVANCE FOR ALL REOURED INSPECTION/AT MSM 4"J 2e. COMPETE DRAWING AT LOWER AREA PROVIDED. /// 81'm X-( TNI, Site Project Manager D.I. PLOT PLAN 0.w Se.bl Se.b •to-- I. o1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NOW"DIRECTION. EXPANSION OF SEWAGE D19MBAL SYSTEMS. 3. DIMENDomea OUTIINF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY rt. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY { ir.....' _ ..._ 3 V L� 1 J ( I \ \ ` 1 LJ i'-1 Ji \ B�"l. y. ifvlt u b } u t >i _..._ J I , r i ,1 �', C "$a �i DEPARTMENT USE ONLY G,..Impe.Rbn By DH. P p Impaction BY DNa Dminmlbn ImOa'BRn By D.te Lpmme,x.: Gc o F c..f4-tor+ S�tc.✓octc.L�.n.•Nz'rT� '(�Pa'✓tit�fi "L�/ 2�o I D'l•tel t!. (tb G Pier fi L�Y� 4(,I Ct�T21e� bo P• tolv.gq-- ACCOUNTING ONLY: AIDF FACE PE CODES FEE INFO AMOUNT REMITTED C/NECKEICASN RECEIVED BY DATE PEIEAIT/SERVICE REQUEST NUMBER INVOICE 2 01 28803 rl n13V .Health Sely.-Enviro.173(1197)