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APPLICATION FOR WEWPUMP PERMIT <br /> 1OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388. 445 N. SAN J0Aa uiN ST, STOCKTON, CA 35201-388 <br /> (209) 488-== <br /> NON R1=UNDABLE PERMT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comphfa is Tripakatal <br /> Application is here by made to the San Joaquin S.Mrty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Devetc;ment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. South Parcel <br /> 13170 W. Grant Line Rd./Buron Rd. Ci-y Tracy Parcel size/APR# 63 acres <br /> Job Address/or APR# 0 California Ave. , Suite 400 <br /> Chevron Pipeline Company Address Bakersfield CA 93309 Phone #805-632-1046 <br /> Owner's Hame erra>_n O-. 747 6330 Brewer Road <br /> Ex loratory Drillina Address Pleasant Grove CA Lic# 437836 Phone *916-991-2999 <br /> Contractor P - 56 <br /> — <br /> Sub Contractor Address Lic# Phone " <br /> i R=CACEMENT WELL 0 MONITORING WELL # ❑ OTHER t _, <br /> TYPE OF WELL/PUMP' N 0 W <br /> DESTRUCTION ❑ CUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # 0 SOIL BORING <br /> �ALLATION 0 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑ New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (�,J <br /> (TYPE OF PUMP) V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL C3 OPEN BOTTOM DIA. OF WELL EXCAVATION 8�� DIA. Of CONDUCTOR CASINGNone <br /> C3 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE Of CASIING/STEEL/PVC PVC DIA. OF WELL CASING <br /> DEPTH OF GROUT SEAL 15' SPECIFICATION IN <br /> ❑ PUBLIC/MUNICIPAL Q DRIVE-11 <br /> Q IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLOl1 <br /> ED 37 ATED GRT BRAND NAME Cement w/5$ Bent. <br /> GROUT SEAL PUMPED: )& Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes E3No <br /> ❑ !IRRITATING <br /> APPROX.DEPTH LOCKING CHESTER 3OX/STOVE PIPE <br /> PROPOSED C13NSTRUCTIONIORILUNG METHOD: NUD RO.AA'7_ AIR ROTARY_ AUGER X CABLE_ OTHER— <br /> her certi,y that I have prepared this acclication and that the work will be cone in accordance with San Joaquin County Ordinances, <br /> I ebb "1 <br /> State Laws, and Rules and Regulations of the San Joaquin CcuntY. Home owner or licensed agent's signature certifies the. following: "I <br /> certify that in the performance of the work forrinich this permit is issued, I shall not employ persons subject to-WCRKKAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sur-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I ;.all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL �IRISANCE FOR ALL REDUIRED =FECTIONS AT=21 40&2423. Complete drawing at. lower .area provided.Title � Date���Signed X� , I I I I I <br /> i t V I I I V I I I I I I b <br /> V I I I 1 1 1 1 1 1 <br /> I II 1111111 <br /> DEPARTMENT USE ONLY U <br /> Date Area <br /> Application Accepted By ��• 5 <br /> Grout Inspection By Date Puce Inspection <br /> ,ByQ Date <br /> Destruction Inspection By Date Co mens: J��w C! # <br /> ACCOUNTING ONLY: I AIDS I FAC# <br /> PE CIIOES ( FEE INFO I AMOUNT REMITTED I CBEC=CASH RECEIVED BY I DATE PERMITISERVICE REDUEST NUMBER I INVOICE <br /> d� I WD I I B I is1P�oO S <br /> I i I I I I <br /> i <br />