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SAIMPPLICATION FOR WELL/PUMP PER AQUIN COUNTY PUBLIC HEALTH S CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TIA1lleetel APPLICATION I814EM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRUE.CHAPTER 9-1115.0 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH US n/ / P I JOB ADORESWR APRT a cTry Stockton PARCEL SIZEJAPN# OF -et ff#POA SETTLING DRY CLEANING DEFENDANTS SDCDI CA 94 OWNER'S NAME c/o Donald T. Bradshaw. Levine-Fricke-Recunon6es 1900 Powell.St., 12th Flr. Emeryvillow E/(510)652-4500 CONTRACTOR ADDRESS (ICI PHONE E 5 11350 Monier Park P915ace 0/706565 PHONE IS 3-9010 SUBCONTRACTOR Transelobal Environmental Geochemistry ADDRESS ancbo Cordova, CA TYPE OF WELLOPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑N+.v❑Reoelr H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O RYPLs OF R1MP1 ❑ OM-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! ® 601E BORING VAPOR e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS A 1:1 INDUSTRIAL ❑OPEN ROTTOM ON.OF WELL EXCAVATION 1-inch DIA.OF CONDUCTOR CASING N/A D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISITE TYPE OF CASINOISTEELTVC N/A DIA.OF WELL CASING N/A D ❑ PURUCIMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL NIA SPECIFICATION cement-bentonite R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY N/A GROW BRAND NAME N/A E ❑ MONITURING GIIOUTSEALPIMAD:3Y. ❑N. CONCRITEPEDESTALRYOWLLER:❑Y. []NeN/A B APPROK.UFPTH multiple borings 5 to 45 ft bgs LOCKING CHESTER BOX/STOVE RPE 5 PROPOSED CONSTRUCTIONIdeLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE. OTHER Hydraulic Push I NE9ERY CERTIFY THAT I HAVE PREPARED THIN APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OMINANCE9,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES 711E FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF Tilt WOP(FOR WHICH THIS PERMIT IS ISSUED,1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION(AWB OF CALIFORNIA.- CONTRACTOR'S HIRING OR OURCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS 8UBJFCT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE CANT MU'y%tt//,CALL 24 HOURS IN ADVANCE FOR ALL MODIFIED INSPECTIONS AT 120/1140/1 422. COMAFTE DRAWING AT LOWER AREA PROVIDED. Blanco X7G✓ Title Site Project Manager D.I. AOT MN 101ew 1.IMI,10&.I. •R. 1. NAMES OF STREEIS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPoBAL SYSTEMS. G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. OLAUCTUGES,INCLUDING COVERED AFEAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING POARTY. LVMD #2 P )iCPT=2t2 A, - ' s CPT 202 o 211 r' V CPT 207 I MW 30 41 - �} y ` CPT. 215 L^�' 1-;MW-5 \ X-CPT 217 C F . CPT-Z03 H CL L CPT 210 . CPT-.214,. ,0 I F i},- I R CPT-�18 F, 'F 1 CPT-21G. �• - ` \ 1 `.--CPT-204 , 1 F, I � - 1 , 1 ....-. .i....... :..... ... DEPARTMENT USE ONLY APalleellen A—'-I R D.0 1 r • Arw Grout ImDmOon BY Dae PmP ImDeetlen BY. _ _ _ _ DNa Uwlrmlbn I...fl..BY v Del. Demme„1.: SIC Mc-"T Chme"I pe Al Lt qj-g09—LV lasued g.2.9�- 2Y�11'�.S II I• ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO AqOUNT REMITIED CHECK#ICABH RECEIVES NY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 1=3 :5=5 Pub.Health$SN.-Enviro.173(1197)