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- - - "aPUCATIDN FDR WELLIPUMP PERMIT - <br /> SAI,,,,AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 446 N. SAN JOAaUIN ST., STOCXTON, CA 96201-388 <br /> (209) 468-=9 <br /> NON RERMR EXPIRES 1 YEAR FROM GATE ISSUED <br /> (Comphti im Tripi"ai <br /> Oeve:c4xnent Title, <br /> Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> plication is here by made to the San Joaquin �"*nty for a permit to construct and/or install the work described. This application is <br /> .ade in compliance with San Joaquin County <br /> 'ervices, Etivironmental Health Division. _ portal Siza/APN# 63 acres <br /> ,op Address/or APN# 13170 W. Grant Line Rd/Byron Rd. City Tia`'- --- phone # 805-_LIZ <br /> 0 0 Cfl 'f25 . A�e33 J400 <br /> wrer's Name Chevron Pipeline Address a ers 2 <br /> 47 Lou se Street <br /> Precision Sampling, Inc. Address San Rafael, CA 94901 Lic# 636387 Phone X415-456-987 <br /> antractor Phone <br /> Address Licit <br /> uo Contractor <br /> SPE OF TELL/PUMP: R=LACENENT WELL Q MONITORING WELL <br /> (3 MEW WELL SOIL BORING2 <br /> W <br /> ❑ DESTRUCTION Q OUT-OF-SERVICE WELL (3 GEOPHYSICAL WELL # Q VAPOR EXTRACTION WELL # <br /> INSTALLATION <br /> ❑ Q WCL SYSTEM REPAIR Q CROSS-CONNECT REPAIR <br /> DEPTH PUMP SET _ FT. FIRST WATER LEVEL <br /> ❑ Mew C3 Repair H.P. O <br /> ;TYPE OF PUMP) <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> NTPI_ . OE— D USE DIA. OF CONDUCTOR CASING <br /> OPEN DIA. OF WELL EXCAVATION <br /> Q INDUSTRIAL C3 apex {� <br /> TYPE OF CASINDIA. OF WELL CASING <br /> G/STEEL/PVC <br /> OCMESTIC/PRIVATE Q GRAVEL PACX/SIZE SEAL SPECIFICATION <br /> Q DEPTH OF GROUT <br /> [j PUBLIC/MUNICIPAL ORIVEN GROUT SEAL INSTALLED SEAL BY GROUT BRAND NAME <br /> (� IRRIGATION/AG [3OTHER CONCRETE PEDESTAL BY DRILLER: Q Yes Q No <br /> GROUT SEAL PUMPED: ❑ Yes ❑ No <br /> Q MONITORING <br /> LOCKING CHESTER SOLI/STOVE PIPE <br /> APPROX.DEPTH <br /> PROPOSED CDMSTAUCTIDNIDRIWNG METHOD: MUD ROTAwT� AIR ROTARY__ AUGER_ UBLE_ 07HER_- <br /> red this application and that the work will be done in accordance with San Joaquin County Ordinances. <br /> i hereby certify that I have preps Home owner or licensed agent's signature certifies the.following: "I <br /> persons subject to-WORKMAN'S COMPENSATION <br /> State laws, and Rules and Regulations of the San Joaquin County. " I certify that in the performance <br /> tacertify that in the perfornance of the work for which this permit is issued, I shall not employ pe <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: Laws of <br /> of the work for which this permit is issued IliS?EC7IONSlA7R091o4883ns 42JeCCompt to lete„drawingatNlowerrNarea providedornia.” THEAPPL1CAlIT <br /> MUST CALL 24 HOU IVO ANCE FOR ALL REQUIREDK <br /> Title Date <br /> Pro cc� 6'^"�^' <br /> Signed X <br /> I <br /> I I I <br /> DEPARTMENT USE 11MLY w� <br /> nate ' Area i <br /> Application Accepted By Date <br /> Date Pump Inspection By <br /> Grout Inspection By <br /> Date__ comments: <br /> Oestruction Inspection By <br /> ACCOUNTING ONLY: <br /> AID# FACS <br /> PE FEE IN <br /> CODES FO AMOUNT REMITTED CHECX3ICASH RECEIVED BY DATE C pERMITISE��� REQUEST NUMBER INVOICE <br /> I� 90 I <br /> i <br /> o � <br />