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APPLICATION FOR WELLIPUMP PERMIT <br /> r JOA11UIN COUNTY PUBLIC HEALTH SERVICES <br /> \z:� ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388. 445 b. SAN JOAauiN ST, STOCXTON, CA 96201-388 <br /> (2091 468.3420 <br /> NOM-REAINDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CmVista is Tr4Goatal <br /> Application is here by made to the San Joaquin cxmty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Oevelcpoent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. South Parcel <br /> Job Address/or APN# <br /> 13170 W. Grant Line Rd./Buron Rd. City Tracy Parcet size/APN# 63 acres <br /> 5080 California Ave. , Suite 400 g05-632-1046 <br /> owner's Name Chevron Pipeline Company Address Bakersfield, CA 93309 Phone <br /> 707 6330 Brewer Road 437836 #916-991-2999 <br /> contractor Exploratory Drilling Address Pleasant Grove CA Lice Phone <br /> Sub Contractor Address Lic# Phone <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ X-,-ACEMENT WELL )0 MONITORING WELL # 3 Q OTHER <br /> ❑ DESTRUCTION (I a)T-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # Q SOIL BORING <br /> Q INSTALLATION Q WE'_L SYSTEM REPAIR Q CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION YELL # <br /> ❑ New ❑ Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL -N11 <br /> (TYPE OF PUMP) W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Q INDUSTRIAL Q 811 OPEN BOTTOM OIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING 2" None <br /> Q OCMESTIC/PRIVATE ❑ GRAVEL ?ACX/SIZE TYPE OF CASING/STEEL/PVC PVC DIA. OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL Q ORIVEN OEPTH OF GROUT SEAL 5' SPECIFICATION <br /> Q IRRIGATION/AG (3OTHER GROUT SEAL INSTALLED 3Y ATED GROUT BRAND NAME Cement w/Bent. <br /> A MONITORING GROUT SEAL PUMPED: ❑ Yes Q No CONCRETE PEDESTAL 3Y DRILLER: Q Yes ❑ No <br /> APPROX. DEPTH <br /> LOCKING CHESTER 30X/STOVE PIPE Stove pipe <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD RoMy_ AIR ROTARY_ AUGER X CABLE_ OTHER_ <br /> I hereby certify chat I have prepared this application and that the wort will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> certify that in the perormance of the work for winich this permit is issued, I shaft not employ persons subject to'WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I slall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICAgT <br /> MUST CALL 24 H04RS IN ADVANCE FOR ALL <br /> (fREQUIRED WPECTIONS AT=21 458.3423. Complete drawing at. lower area provided. � <br /> Signed X /-�-� Title Dated d' <br /> DEPARTMENT USE ONLY <br /> Arca <br /> Application Accepted BY Date �j <br /> Grout Inspection 3y Date Pump Inspection 3y Date <br /> Oestruction Inspection 8Y Date Comments: <br /> FICCaUMTING ONLY. I AID# I FACS <br /> PE CODES FEE INFO AMOUNT REMITTED I I�ECXJ<ICASH RECEIVED B DATE PERMITISEAVICE REDUEST NUMBER IgY010E <br />