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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV.,,3 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complef4 IB Tr(pl'Ic4f41 <br /> APPI-ICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY rOn A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COM)QI I �c,F lNGY1o.4St <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 <br /> 15. AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 1 <br /> JOS ADDRESS/OR APNI 16 7 7 7 S . Howland CIT"_I-q t17 r r)TT PARCEL SIZE/APNI <br /> OWNER'S NAME Oxy Chem (Treatek-Cra as AgeA&,,*a 202 Val Dervin Prkwy Str>"r# 983--68.10 <br /> W _ <br /> CONTRACTOR C l a r k P 1 1 ADDRESS 2024 (�L LIC/3 715 6 0 PHONE#-4L&2-=-7-6 7 6 <br /> C h a-r-ter <br /> SUB CONTRACTOR +►"[1 ADDnFSB LICPHONE <br /> TYPE OF WELLIPUMP: 11NEW WELL 0)(AEPLACEMENT WELL 7L,.JL MONITORING WELL J PW 2 4—5 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI .i <br /> ❑ <br /> (TYPE OF PUMP) New❑Ronelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL n <br /> ❑ OUT-oF-SEnVICF WEI 1. ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING p <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "- --- " <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM D .I OF WELL EXCAVATION 12 IT— 4y/why, DIA.OF CONDUCTOR CASING <br /> 11DOMESTICIPRIVATE �c�g30RAVEL PACK/SIZE 21 f 1 TEFIJPVC t DIA.OF WELL CASING ���$TT n <br /> 11 PURI IC IMUNIC IPAL 11 DRIVEN DEPTH O GROUT SEAL SPECIFICATIONQ F;A E lE A /e R <br /> ❑ IRRIGATION/AG ❑OTHER GROAT SE L INSTALLED BY GROUT BRAND NAM @ 1-�1" E <br /> MONITORING OUT SEA PUMPED:fly N CONCRETE PEDESTAL eY DRILLEFXCI Ye. [IN. S <br /> APPROX.DEPTH L CKING CHES BOX/ OVE PIPE g <br /> PROPOSED CON4TAVCTIONIDi#WNG PAET1400: MUIP ROTARY X RO AR AUG CABLE R <br /> \\ P A <br /> I HE9FBV CERTIFY THAT 1 HAVE PREPARED HIS AFRICA O ANO T IAT THE WO Ll.BE NE IN ACCORDA WITH BAN JOAQUIN CO O ANCES,STATE UWP.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COV HOME O KENS,.AGENT C.N URF CERTIFIES THE OLL.OWING:'I CERTIFY THAT 1 THE PERFORMANCE OF T11E WOR(FOR WHICH <br /> THIS PERMIT 18 ISSUED,18HALL NOT EMPLO PERSONS EJECT TO ORKMAN'4 COM ATiON LAWS OF CALIFORNI CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 1 CERTIFY T fE ORM N E OF THE RC FOR WHICH IIS PERMIT IS ISSUED,I SH E PLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' N T C URS N DVANCE F ALL REOUIRE INSPECTIONG AT 120414 -2422 COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br /> Slt,nedx Tit VP Clark el Inc D.t.1/28/97 <br /> OT PLAN 1Dr to .Lel Rode 'to <br /> 1. NAMES OF STREETS OR ROADS N REST TO OR BOUNDI G THE PRO -RTU. 4. LOCATION USE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING IMENSI NS AND N H DIRECT 0 EXPANSI OF AGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATI OF A L EXISTING ND PRO D R. LOC ON OF LLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ARE RU A8 PATIO DRIV YS,AND WALKS. ON/HE PftopEr4y OR ADJOINING PROPERTY. <br /> L.,a ✓� eJ � <br /> Y . <br /> l!"T rw <br /> l <br /> .. .... .... ....... . <br /> JAN-3,01 97 <br /> L .. <br /> �IIV SAN JOAQUIN COLINTY , <br /> _,. C:HEAL <br /> DEPARTMENT USE ONLY <br /> ApPllcetbn Ac—pled By Dote I� 1A:� Are. <br /> Grout ImDecllon BY Dote Pu Rlmpectlon By Date <br /> Doo mrellon In pwlo++By <br /> Dote <br /> Commenu: <br /> ACCOUNTING ONLY: AID/ FAQ# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC ARIL RECEIVED BY DATE PERMIT/4EnVICE REQUEST NUMBER INVOICE <br /> 44-ng4-4-04; <br /> -Oak 4mm AO <br /> Pub.Health Serv.-Enviro.173(3/96) -y���� 0�"�Mth <br />