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APPLICATION FOR WELLJPUMP PERMIT <br /> IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388. 445 R- SAN JOAQUIN ST, STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> MOM RE=IIMDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempiete is Tnpfiieanl <br /> AFQlicati°n is here by made to the San Joaquin cxnty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin county Develc¢nent Title, Chapter 9-1115.3 and the Standards of San Joaquin County <br /> Nort�lParcel <br /> Services, Environmental Health Division. <br /> city 63 acres <br /> Job Address/or APR* 13170 W. Grant Line Rd./Buron Rd. Tracy Parcel size/APR# <br /> 5080 California Ave. , Suite 400 805-632-1046 <br /> Chevron Pipeline Company Address Bakersfield CA 93309 Phone <br /> Owners Name ,1-�t..A 75+7 6330 Brewer Road 437836 0916-991-2999 <br /> errain Phone <br /> Contractor Exploratory Drillinc Address Pleasant Grove CA Licit <br /> Address 95668 Lic# Phone <br /> sub Contractor _ <br /> R='�CEMEAT WELL Q MONITORING WELL # ❑ OTHER <br /> Typ° DF WELLlp�p' izSTiAL�LAT� <br /> ❑ SOIL BORING <br /> Q art-CF-SERVICE WELL Q GEOPHYSICAL WELL # ❑ <br /> Q WELL SYSTEM REPAIR Q CROSS-CONNECT REPAIR Q VAPOR EXTRACTION WELL # <br /> Q New Q Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF YVELL CONSTRUCTION SPECIFICATIONS <br /> 8 11None <br /> OPER 307DIA. OF CONDUCTOR CASING <br /> Q INDUSTRIAL C2 OPEN 0[A. OF WELL E(CAVATION PVC OIA. OF WELL CASING 21 <br /> ❑ OCMESTIC/PRIVATE Q GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br /> DEPTH OF GROUT SEAL 15, SPECIFICATION <br /> ❑ PUBLIC/MUNICIPAL Q DRIVEN NAME Cement w/5% Bent. <br /> Q IRRIGATION/AG Q OTHER GRCUT SEAL INSTALLED BY ATED GROUT BRAND <br /> ❑ y0N170RING <br /> GROUT SEAL PUMPED- I( Yes Q No CONCRETE PEDESTAL BY DRILLSR: Q Yes Q No <br /> APPROX- DEPTH LCCXING CHESTER BOX/STOVE PIPE <br /> PROPOSED CDNSTRUCTIDIUORILLING METHOD: MILD ROTA+c-Y_- AIR ,ROTARY_ AUGER X CABLE_ OTHER_ <br /> I have prepared this apelication and that the work will be done in accordance with San Joaquin cou ryoiOrdinances, <br /> di an es, <br /> I herevy certify thatP sigmture <br /> State Laws, and Rules and Regulations of the san Joaquin -unty. Home owner or licensed agent'spersons subject to- COMPENSATION <br /> cer-.ify that in the per=orrsance of the work for which this permit is issued, I shall not employ pe performance <br /> Laws of California-" Contractor's hiring or sza-cantractTngsignature pec to er-cifUOtiKMAN�STCOMPENSATION Laws of Calollowing: certify ifornia.at in "1LT E APPUCa3t <br /> of the work for which this pernit is issued, I ;.hall employ pe �• <br /> MUST CALL 24 H0PRS IN ADVANCE FOR ALL REDUIRED gWECT[ONS AT(2021 489-3423. Complete drawing at. Lower .area provided. <br /> Titley.�i�^ Date P"S� <br /> Signed X'� <br /> I I 1 1 1 1 1 1 I I I I I c <br /> S I I i t I I I I l l l l l l <br /> III II IIII 1111 I II I <br /> 7-1 1 1 V I I I <br /> DEPARTMENT USE ONLY <br /> Date ��JT S Area <br /> Application Accepted BY C <br /> Grout Inspection By <br /> Date Pump Inspection 8y Date <br /> Destruction Inspection BY Date c� Z Comments: &-/, <br /> ACCOUNTING ONLY: I AID# I FAGS ~ `' <br /> PE CODES F INFO AMOUNT REMITTED I C8ECXACASH I RECEIVED BY I DATE PERMRISERVICE REDUEST NUMBER INVOICE <br /> 2902-1 u/� �v 13 I z�3 s� W0O53.2, <br /> I <br />