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- - - iPPUCATION FOR WELLIPUMP PERMIT - <br /> 1OA(1UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388. 446 N. SAN JOAaUIN ST., STOCKTON, CA 96201-388 <br /> (2091 458-3420 <br /> NON RERINDABLE PERMIT E)(P1RE3 1 YEAR FROM DATE ISSUED <br /> (Compbn iR TripGcanl <br /> Application is here try made to the San Joaquin C=VZY for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Deve:cgne^t Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> South Parcel <br /> Services, EnvirormentaL Health Division. 63 acres <br /> Job Address/or APN# 13170 W. Grant Line Rd./Buron Rd. city Tracy Parcel size/APN# <br /> Ca ifornia Ave. , Suite 400 805-632-1046 <br /> Chevronerrain CA Lic# Phone n Pipeline Company Address Bakersfield CA 93309 Phone <br /> owner's Name �c2�Ary� , 6330 Brewer Road 437836 #.916-991-2999 <br /> Drilling_ Pleasant Grove <br /> contractor Exploratory _ Address95668 <br /> Address Lict Phone <br /> Sub Contractor <br /> ACEHEMT WELL )a MONITORING WELL $ 3 ❑ OTHER <br /> TYPE�L/PUMPt C3 NEW WELL ❑ x- '. ❑ SOIL 30RING <br /> ❑ DESTRUCTION ❑ CU -OF-SERVICE WELL G GEOPHYSICAL WELL # <br /> ❑ INSTALLATION (3 - SYSTEM REPAIR 13CROSS-CDMHECT REPAIR (3VAPOR EXTRACTION WELL # <br /> ❑ Nes+ ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> W <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE. DF WELL CONSTRUCTION SPECIRCATIONS <br /> DIA. OF CONDUCTOR CASING None <br /> ❑ INDUSTRIAL G OPEN 30TTCM DIA. OF WELL E)(CAVATION _ 2„ <br /> c TYPE OF CASI-AG/STEEL/PVC PVC DIA. OF WELL CASING <br /> ❑ DCMESTIC/PRIVATE [3GRAVELPACX/SIZ_ 51 SPECIFICATION <br /> ❑ PUBLIC/MUHICIPAL ❑ DRIVEN DEPTH Of NS SEAL <br /> GROUT SEALLINS3Y <br /> ATED GROUT BRAND NAME Cement w/Bent. <br /> ❑ IRRIGATION/AG ❑ OTHER <br /> It MCNI70RING GROUT SIAL PUMPED: CI Yes E3 NO CONCRETE PEDESTAL BY DRILLER: (3 Yes ❑ No <br /> LCCXING CHESTER 30X/STOVE PIPE <br /> Stove pipe <br /> APPROX. DEPTH <br /> X CABLE_ OTHER <br /> PROPOSED CDNSTRUCTIOIUDRIULNG METHOD: MUD ROTAZT AIR ROTARY_ AUGER <br /> I hereby certify that I have prepared this application and that the wort will be done in acraraancr 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 performance of the work for whit+ this permit is issued, I shall not employ persons subject t0•WCRKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certities the following: " I certify that is the performance ` <br /> of :he work for whica -,his permit is issued, I >'+alL emoloy persons subject to WORKMAN'S COMPENSATION Laws of California." THE APQUCaN7 <br /> MUST CALL ZR HOURS c: ADVANCE FOR <br /> ALL at 9WECTIONS AT (1093 AM3423. CcmpLete drawing at. lower .area provided. <br /> Signed X <br /> / G � L���� Title Dated c1�Y <br /> I I IIII I I I ( <br /> i 111111 I III <br /> IIIIIIII I I II I II i <br /> DEPARTMENT USE ONLY ! / <br /> Date �✓ � _ Arca <br /> Application Accepted 3y <br /> Date Pump Inspection 3Y Date <br /> Grout Inspection 3y <br /> Destruction Inspection 3y Date Comments OQ��"'i-a�.C� �f/ <br /> ACCOUNTING ONLY I AID# I FAC-9 <br /> PE CODES FEE INFO I AMOUNT REMMED I CSECXXCASH I RECEIVED 3 I DATE I PERM•�RISERVICE REQUEST NUMBER INVOICE <br /> C) I t I �� 1 3 0o 53. <br /> i I i I I <br /> I I <br />