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_.._.. •-•- M.- APPLICATION FOR WELL[PUMP PERMIT - -- - - - <br /> S OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �-� ENVIRONMENTAL HEALTH DIVISION U <br /> P 0 SOX 388. 445 IL SAN JOAQUIN ST.. STOCXTON, CA 96201-388 <br /> (2091 468-3420 <br /> NON-REIINDABLE PERMR EXPIRES 1 YEAR FAOM DATE ISSUED <br /> (Camplste in TrapIMI I <br /> Application is here by made to the San Joaquin :.xa+tY for a permit to construct and/or install the worst described. This application is <br /> made in compliance with San Joaquin County Develoaoent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> services, Environmental Health Division. Parcel Size/APR# 63 acres <br /> Job Address/or APN# 13170 W. Grant Line Rd/Buron Rd-, City ==4 _ phone SOS-632-7 046 <br /> 5080 Cflif2rn ' AyIaJ400 <br /> owner's Name Chevron Pipeline Address a ers 1e <br /> 47 Lou se Street <br /> Precision Sampling, Inc. Address San Rafael CA 94901 Lic# 636387 Phone #415-456-987 <br /> Contractor Phone # <br /> Address Lac# <br /> sub Contractor <br /> NEW WELL ❑ R=rLACEMENT WELL ❑ MONITORING WELL * 2 <br /> TYPE nc 9— L LUMP: ❑ j SOIL BORING <br /> --- ❑ DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # VAPOR EXTRACTION WELL # <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROsS-CONNECT REPAIR ❑ <br /> DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑ New [3 Repair H.P. O <br /> (TYPE OF PUMP) <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IgTE3l�USE DIA. OF CONDUCTOR CASING <br /> N BOTTOM DIA. OF WELL EXCAVATION <br /> ❑ INDUSTRIAL ❑ OPEDIA. Of WELL CASING <br /> [3DOMESTIC/PRIVATE [3 GRAVEL OF CASING/STEEL/PVC GRAVEL PACK/SIZE SPEC IfICAT ION <br /> (3PUBLIC/MUNICIPAL E3 DRIVEN <br /> OF GROUT SEAL DRIVEN GROUT BRAND NAME <br /> GROUT SEAL INSTALLED BY <br /> IRRIGATION/AG ❑ OTHER GROUT SEAL PUMPED: ❑ Yes Q No CONCRETE PEDESTAL BY DRILLER: 13 Yes Q No <br /> [3 <br /> ❑ MONITORING <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING !METHOD: MILD ROTARY_, AIR ROTARY__ AUGER__, CABLE__ OTHER__ <br /> in County Ordinances, <br /> [ hereby ? Home owner or licensed agent,sons subject to yORKMANCS1oCOMPEHSATiON <br /> certify that I have ,,pared this aerlication and that the work will b, done in accordance witture h San raga <br /> State Laws, and Rules and RegulatiorLs of the San Joaquin County- u I certify that in the performance <br /> certify that in the per of the work for which this permit is issued, I shall not ertoloy Pe <br /> to ,sons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> Laws of California-" Contractor's hiring or sub•crntracting signature certifies the following: <br /> La the work for which this permit is issued, I slall employ Pe <br /> MUST CALL 24 HOU IN/AD ANCE FOR ALL REDUIRED UWECTIONS AT(2Dl)489-=3- <br /> MUST <br /> ��3- Complete drawing �r l C`r aK provided. Date Iz 24 w C, <br /> Title I <br /> Signed X <br /> { I I <br /> { I <br /> DEPARTMENT USE ONLY ' <br /> Date Area _ CC <br /> Application Accepted By 7 <br /> Date Pump Inspection By, <br /> Grout Inspection By % 6� <br /> Date Comments: 4156 <br /> Destruction Inspection By ('y <br /> 1CCOU11I71gG ONLY: <br /> AID# FACS <br /> O AMOUNT REMITTED QIE=XCASH RECEIVED BY DATE PERMITISERVICE REDUEST MUL38ER INVOKE <br /> PE CODES FEE INF <br /> ® <br /> 9 <br /> '/Q <br /> I <br />