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-,APPL1CAT10N FOR WELLIPtIMP PERMIT -- - -- -- <br /> 'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION `s <br /> P 0 SOX 388. 445 N. SAN JOAQUIN ST, STOCMN, CA 95201-388 <br /> (2091 458-3420 <br /> NON REUNDABLE PfRNfT EXPIRES 1 YEAR fRON DATE ISSUED <br /> (CampMoa is Tryfreatsi <br /> Application is here by made to the San Joaquin S-LntY for a permit to construct and/or insta(L the work described. This application is <br /> made in campLiance with San Joaquin county Deve:cpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. North Parcel <br /> 13170 W. Grant Line Rd./Buron Rd. City Tracy Parcel. Size/APN# 63 acres <br /> Job Address/or APN# 5 Ca ifornia Ave. , Suite 400 <br /> Chevron Pipeline Company Address Bakersfield CA 93309 Phone 805-632-1046 <br /> Owner's Name „��r,x 1)417 6330 Brewer Road <br /> errain -991-2999 <br /> 437836 0916 <br /> contractor Exploratory Drilling Address Pleasant Grove C� Lice Phone <br /> Address Licit Phone <br /> Sub Contractor ” <br /> TYPS OF WELL/PUMP: [3 NEW WELL C3 �LACE14ENT WELL C MONITORING WELLS 1 (3OTHER <br /> ❑ DESTRUCTION ❑ O:R-OF-SERVICE WELL ❑ GEOPHYSICAL WELLS ❑ SOIL BORING <br /> ❑ INSTALLATION ❑ LEL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL rv� <br /> (TYPE Of ?UMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 811 DIA. OF CONDUCTOR CASING None <br /> ❑ INDUSTRIAL CI OPEN BOTTOM DIA. OF WELL EXCAVATION <br /> TYPE OF CASING/STEcL/PVC PVC DIA. OF WELL CASING 2" <br /> ❑ DOMESTIC/PRIVATE Q GRAVEL PACK/SIZE <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 51 SPECIFICATION <br /> Q TRRIGATION/AG ❑ OTHER <br /> GROUT SEAL INSTALLED 3Y ATED GROUT BRAND NAME Cement w/Bent. <br /> X MONITORING GROUT SEAL PUMPED: ❑ Yes C3No CONCRETE PEDESTAL BY DRILLER: (3Yes C3No <br /> APPROX.DEPTH - <br /> LOCKING CHESTER BOX/STOVE PIPE Stove pipe <br /> PROPOSED C13USTRUCTIoXIOPILUNG MEWO: MUD ROTAR'T__ AIR ROTARY_ AUGER_ to CABLE_ OTHER_ <br /> I herby certify that I have prepared this aorl.ication and wat the work will be core in accordance with San Joaquin County Ordinances, `Jlf <br /> t' certifies <br /> State Laws, and Rules and Regulations of the San Joaquin Cont <br /> uy. Home owner or Licensed agenWORKMANeSrCOMPENSATION <br /> certify that in the perfor mance of the work for smith this permit is issued, I shall not employ pe object to <br /> Laws of California." Contractor's hiring or sem-contracting signature certifies the following: a I certify that in the performance <br /> of :he work for which this permit is issued, I sraLL &wtoy persons subject to WORKMAN'S COMPENSATION Laws of Catifornia.l' THEAPPUCAKT <br /> MUST CALL 24 HOURS IN ADVAKC>�tOR LL AEQff�U�IRED =?E=GXS AT ROJI 48&3423. Comotete drawing at. lower ,area provided. <br /> TitLeC� Date Signed X <br /> I I i I i I I I I <br /> IIL TiI II I ( II <br /> DEPARTl1E1(T USE ONLY <br /> Date a �5ZZ5 Area <br /> Apptieation Accepted BY <br /> Grout Inspection By Date Pump Inspection BY Date <br /> Destruction Inspection BY Date Carments: <br /> ACCOUNTING ONLY: I AID# I FACS <br /> PE CODES EEE INFO AMOUNT REMITTED I CBE=CASH I RECEIVED BY I DATE PERMITISERYICE AEDUES7 NUMBER INVOICE <br /> I I i i I <br />