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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERI--IES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O..BOX 988,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 40e-3410 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) \D <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION 16 MADE IN COM iEr"•" "JgUq"yl` <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION(t <br /> JOB ADDRESSOR APNI1.6 7 7 7 q _ IJ n .t 1 aSL d CITYfat-kl-�9-p PARCEL SIZE/APNI <br /> -- — <br /> OWNER'SNAME Oxy Chem (Treatek-Cra as A erA1)*s1B_ 202 Val Dervin P - kwy S SIE. 983-6810 <br /> CONTRACTOR it GT a l l ADDRESS o n n/, n <br /> — .. t n Lh_a_rt a Iuc,l;7 1 5 Fi{1 PHONE#4_6_2_—_7f5_7_6 <br /> zZrZ�1 — ` <br /> OUR CONTRACTOR ADDRESS Lice PHONE 9 <br /> TYPE OF WELL/PUMP: ❑ NEW WELL (0)PEPLACEMENT WELL R MONITORING WELL+I P!A? 7% —5 0 ❑ OTHER <br /> ❑ INSTALLATION 11WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR l 1 ❑ VAPOR EXTRACTION WELL/ <br /> ❑ <br /> (TYPE OF PUMP) New 11Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-Or-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL Lj�� <br /> CDNSTRUCTION SPECIFICATIONS? t' L �yA <br /> ❑ INDUSTRIAL ^❑OPEN BOTTOM �/I VDIINOF WELL EXCAVATION 12 1r � DIA.Or CONDUCTOR CASINO �❑ DOMESTICIPRIVATE N13 GRAVEL PACK/SIZE Z 1 (fTY Qf.S.AgI /STEEL/PVC�'� 1�� DIA.OF WELL CASINO� C /O It nD <br /> 11PUBLICIMUNICIPAL ❑DRIVEN (,DEPTH GROUT SEA �. 1 1 SPECIFICATIONS 9 ya !7(� __ R <br /> ����❑ IRRIGATION/AO ❑ 1 e <br /> OTHER GROUT S L INSTALLED BY GROUT BRAND NAM E <br /> XQ MONITORING ROUT SE PUMPED:flY No c CONCRETE PEDESTAL BY DRILLER Ye. ❑No S <br /> APPROX.DEPTH CKING CHERBOX OVE PIPE S <br /> PROPOSED CONSTRUCTTON/DRI\LUNG METHOD: MUD ROTARY X / IR RO A AUG CABLE__?= R <br /> I HE9ESY CERTIFY THAT 1 HAVE PREPAntq THIS APPLICATIO AND T A WO BE NE ORDAN WITH BAN JOAQUIN CO NTY O ANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COU . HOME O LICENSED AGE 'S�SIGN URE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT WTHE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1814ALL NOT EMPL jY PERSONS EJECT T WORKMAN'S C M ATION LAWS OF CALIFORNI CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY TH lE PERFORMANCE OF THE ORK FOR WHICH 18 PERMIT IB ISSUED,I SH E PLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T C T T C URS IN ADVANCE F R ALL REGUR INSPECTIONS AT 1200►4 J42 COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SipnedX TI . VP Clark Y el Inc Date <br /> 1/28/97 <br /> OT PLAN IDI to argil Beale 'to---�/ <br /> 1. NAMES OF STREETS OR ROADS NEAREST T�OR BOUND D THE PRO 4. LOCATION USE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVIN<�MENB NS AND NORTH DInEC 10 EXPANSIP OF EWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF L EXISTIN( AND PRO ED S. LOCATION OF LLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED A B SU H AS PATIO,DRIV AYS,AND WALKS. / ON:THE PROPE OR ADJOINING PROPERTY, <br /> l <br /> PL AIv <br /> PA <br /> . <br /> JAN 3 01997 <br /> SAN JOAOUIN COUNry , <br /> . .... .:. . TH SERVICES <br /> ................. <br /> DEPARTMENT USE ONLY ENVIRONMENTAL HEA <br /> AppSeatlon Accepted BY Arsa <br /> Grout Impeellon BY Dote Pump Inapoction By Date <br /> De.traetlon Impectlon BY Date <br /> Cemmentr. <br /> ACCOUNTING ONLY: AIDE FAC, <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI ABH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 8 '14 1 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />