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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERB .:S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON.CA 95201-988 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Trorse$t$) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRO*ENTAL HEALTH DIVISION. <br /> JOSADDRESSMRAPN/ 2905 West Benjamin Holt Dr. CITY Stockton PARCEL SIZE/APNI <br /> OWNER'SNAME Chevron Products U.S.A. ADDRESS 6001 Bollinger Canyon Rd PHONE♦ <br /> CONTRACTOR Geraghty & Miller, Inc ADDRESS 1 050 Marina Way nth 571 L��jyE1 23332ot <br /> Tda, f zmat Drilling 554979 sio <br /> SUB CONTRACTOR ADDRESS <br /> TYPEOF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL OTHER 59 /`9 IO <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR VAPOR EXTRACTION WELLi <br /> ❑Nwv❑FipdrH.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL 1 ❑ SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED ULE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10 11 & 12 1I DIA.OF CONDU'TOR CASING <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGUSTEEL/PVC_ Pyr DIA.OF WELL CASING 7 II <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 21 SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY West Hazma t GROUT BRAND TAME <br /> ❑MONITORING GROUT SEAL PUMPED:❑Yr. JXNo CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne <br /> APPROX.DEPTH 24 & 35 1 LOCKING CHESTER BOX/STOVE PPE <br /> PROPOSED CONSTRUCTIONnMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES, <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN TRE PERFORMANCE OF THE WORK FOR WF <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTII <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT 7O WORKMAN'S COMPENSATION LAWE <br /> CALIFORNIA.' THE AZ ,T MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 12001409-1423.COMPLETE DRAWING AT COWER AREA PROVIDED. <br /> Alslon.d x Till. Vii/►U / La D� 1 D.I. <br /> Ke <br /> p ni- I'—� E5yamPL, , <br /> "uC. OT PLAN IDR to Sc 10 Sol, � 3 <br /> i.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DI POSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS Wr"N RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I A/te <br /> $ J "►iN <br /> o <br /> C _ <br /> l <br /> J <br /> 1 <br /> l <br /> Tzi1l�. <br /> I <br /> s;rnuctz'�tF <br /> . <br /> ....... <br /> _'�) DEPARTMENT USE ONLY <br /> Applic.tlon A..Wl d By // 1 C K'�{(-�. D.t. Ar <br /> Grout Impoetion By D.t. Pump In.p.otlon By I D.t. <br /> D..truetlon Imp-tion By Opt. i <br /> t:pmm.nt.: J�,DA� �?Ij rti� f ic,st 2- ct�JS' '(�l^LaL. h. cirLlU�t� L�"1� P S-cz33 <br /> ACCOUNTING ONLY: AI131 1AC1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK♦/CASH RECEIVED BY DATE FERMIT/SERVICE REOUFAt NUMBER INVOICE <br /> 1 �3 410 O Mylta t•731 L 1 <br />