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APPLICATION FOR WELLIPUMP PERMIT <br /> 10AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �--� ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 H. SAN JOAQUIN ST.. STOCKTON, CA 36201-388 <br /> (2091 468-3420 <br /> NOX.REFONDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C"Vista in Tr4Goanl <br /> Application is here by made to the San Joaquin minty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County 0eveicQment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. North Parcel <br /> Job Address/or APN# <br /> 13170 W. Grant Line Rd./Buron Rd. city Tracy Parcel size/APN# 63 acres <br /> 5080 Ca ifornia Ave. , Suite 400 g05-632-1046 <br /> Owner's Name Chevron Pipeline Company Address Bakersf ield, CA 93309 _ Phone # <br /> errain 7 0750y- 714"7 6330 Brewer Road 437836 #916-991-2999 <br /> contractor Exploratory Drilling Address Pleasant Grove CA Licit 437836 <br /> 56 W <br /> sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP- ❑ NEW WELL ❑ R-'AGEMENT WELL CY MONITORING WELL # 1 ❑ OTHER <br /> ❑ DESTRUCTION ❑ CUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL 30RING � <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> ❑ New ❑ Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF ?UMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑ OPEN 30TTOM DIA. OF WELL EXCAVATION 811 DIA. OF CONDUCTOR CASING None <br /> ❑ OCMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC PVC OIA. OF WELL CASING 2 <br /> 11 <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 51 SPECIFICATION <br /> (3 IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED 3Y ATED GROUT BRAND NAME Cement w/Bent. <br /> X MONITORING GROUT SEAL PUMPED: ❑ Yes ❑ No CONCRETE PEDESTAL 3Y DRILLER: ❑ Yes ❑ No <br /> APPROX.DEPTH LOCXING CHESTER SOX/STOVE PIPE Stove pipe <br /> PROPOSED CONSTRUCTIOKIDRILLING METHOD: MUD ROTARY AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin Canty. Hone owner or Licensed agent's signature certifies the. following: "I <br /> certify that in the performance of the work forraich this permit is issued, I shall not employ persons subject to-WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of :he work for which this permit is issued, I >zai.L emotoy persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPUCANT <br /> MUST CALL 24 HOURS IN ADVANC OR LL REQUIRED 9S7MGN3 AT RDS)4M3413. Complete drawing at. lower .area provided. <br /> TitleSe <br /> e- Date <br /> Signed X <br /> I I I I I <br /> II <br /> I � I N� <br /> DEPARTMENT USE ONLY <br /> Date Arca <br /> Application Accepted By <br /> Date Pump Inspection BY Date <br /> Grout Inspection 3y <br /> Destruction inspection Sy DateComments: <br /> i <br /> ACCOUNTING ONLY: I AID# I FACS <br /> PE CODES TEE INFO AMOUNT REMITTED I �ECI(IICASH I RECBVEO SY DATE PERMITISERVICE REQUEST NUUBER IUVOICE <br /> I <br />