Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT - <br /> JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i P 0 BOX 38L 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201-388 <br /> (2091 468 O <br /> MON.RL=UNOA8LE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (cm*iata in Tr4Geaal n <br /> Apptic� ��12®IWe9fsf Jeaquina� Joaquin <br /> aquincunty for a ritlee Chapter 9-11115.3 and the Starmit to construct and/or ndards of San Joaquill the work n�County PublThis ictH Health <br /> `" <br /> made in cl <br /> Services, EnVlrortroentaL Health Division. Parcel Size/APN# 63 acres <br /> Job Address/or APN# 13170 W. Grant Line Rd/BUron Rd. city Trartl phone # 805-ti3 704 6,, <br /> 5080 C�.. 3* -,rn�g A�33Q9400 <br /> Owner's Name Chevron Pipeline _ Address Bakers ie <br /> 47 Lou se Street <br /> Contractor <br /> Precision Sampling, Inc._ Address San Rafael, CA 94901 Lic# 636387 Phone #415-456-9875 <br /> Lic# Phone # <br /> Address <br /> Sub Contractor � <br /> R=rLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER iV <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ SOIL BORI 2 0 <br /> ❑ DESTRUCTION ❑ OUT-OF'SERVICE WELL ❑ GEOPHYSICAL WELL # 7S� VAPOR EXTRACT LL # <br /> ❑ INSTALLATION ❑ W—L SYSTEM REPAIR ❑ CROSSCONNECT REPAIR FT. 0 RST WATER LEVEL <br /> DEPTH PUMP SET <br /> ❑ Ne++ ❑ Repair H.P. V <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFlCATIONS <br /> ❑ <br /> DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> ❑ INDUSTRIAL OPEN BOTTOM <br /> TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] DOMESTIC/PRIVATE [3 GRAVEL PACK/SIZE SPECIFICATION <br /> DEPTH OF GROUT SEAL <br /> [] PUBLIC/MUNICIPAL ❑ DRIVEN GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL PUMPED: ❑ Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> ❑ MONITORING <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH X <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> red chis a Citation and that the work will be done in accordance with San Joaquin County Ordinances, <br /> I hereby certify that I have preps pp persons subject to WOR►�IAN,S COMPENSATION <br /> State Laws, and Rules ra d Regulations <br /> Of nne of workhfo �+hich�th s permit is ais�sued owner <br /> shallcnot emptoytpe signature certifies the following: "I <br /> certify that in the Pe " I certify that in the performance <br /> persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT— <br /> Laws of California." Contractor's hiring of sub-contracting <br /> �Pe signature certifies the following: <br /> of the work for which this permit is issued, <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REDUIRED UISPECTIONS AT(2091 4483423. Complete drawing at Lowerarea Datelt t� 9 <br /> Titte •a; <br /> Signed X ,�• <br /> DEPARTMENT USE ONLY <br /> Dat [/ <br /> Application Accepted By Dat <br /> Date Pump Inspection Sy <br /> Grout Inspection By Date Comments: CPO <br /> Destruction Inspection By <br /> ACCOUNTING ONLY: <br /> AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CBECX/ICASH REC ED BY DATE PERMITISEWCEEQUE T NUMBER INVOICE <br /> ,,-,o 00 5` <br />