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APPLICATION FOR WELLIPUMP PERMIT -- - <br /> S OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 445 N. SAN JOAQUIN ST, STOCXTON, CA 96201.388 <br /> (2091 468-3420 <br /> JA IN `� 198 qOM-Rt?I1gDABlE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompMm is Triplieaal <br /> it to constt andor install the <br /> Appli�l d ®IV{�i�I E he naCounty�Dev .cfinentoTitleerChapter 9-1115 3 and/ tan St nda ds of SanescribedJoaquiinn County aPublliction Healt� <br /> made in c W?-#Si+9I <br /> Services, Environmental Health Division. <br /> Parcel Sizt/NPN# 63 acres <br /> Job Address/or APNN 13170 W ron Rd._Grant Line RVD-YCity -Z=CZ <br /> Wo Cf2ifogrn� A§e� 0A400 phone 805-632-1046 <br /> Owner's Name Chevron Pipeline — Address a ers 2e <br /> 44anLRa aelstreet <br /> Precision Sampling. Inc. _ Address S CA 94901 Lic# 636387 Phone #415-.456-9875 <br /> Contractor Phone <br /> Sub Contractor <br /> Address Lic# - <br /> ,L- ��CEMENT WELL ❑ MONITORING WELL ;V_ <br /> ❑ OTHER <br /> TYPE OF HELL/PUMP: ❑ NEW WELL ❑ <br /> ❑ DESTRUCTION ❑ CLR•OF-SERVICE WELL ❑ GEOPHYSICAL WELL # 7d]C SOIL BORI 2 0 vl <br /> [3 INSTALLATION <br /> New C3 [3 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR FT. F❑IRSTVAPOR <br /> WATERTLEVEL LL <br /> CT <br /> (] NeRepair H.P. DEPTH PUMP SET <br /> (TYPE OF PUMP) G <br /> INTENDED USE TYPE WCONSTRUCTION SPECIFICATIONS <br /> OPEN BOTTOM OIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING - <br /> ❑ INDUSTRIAL ❑ DIA. OF WELL CASING <br /> STEEL/PVC <br /> (] DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/ SPECIFICATION <br /> [] PUBLIC/MUNICIPAL 13 DRIVEN OF GROUT SEAL DRIVEN GROUT BRAND NAME <br /> [IIRRIGATION/AG C3 OTHER <br /> GROUT SEAL INSTALLED BY <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑ Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: NI ROTAwY_ AIR ROTARY__ AUGER__ CA8LE_ OTHER X <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State laws, and Rules and Regulations of the <br /> San rsichqhii Cperniit is issuedner or d, I shall ensed not of employtperso signature certifies <br /> to�fWORKMAN'SfCOM COMPENSATION <br /> certify <br /> certify that in the performance of the work11 1 certify that in the <br /> nce <br /> Laws of California." Contractor's hiring or sub-contractingsubject toture ifies the <br /> Sfollowing: N Laws of California., T E APPLICANT <br /> of the work for which this permit is issued, I s:%all employ persons <br /> MUST CALL 24 HOUPS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)488.3423. Complete drawing �at lower area provided. <br /> /44-4 � Title 1/°�� Zy�- Date 12 27 9 <br /> (Signed X l <br /> I <br /> DEPARTMENT USE ONLY t <br /> Dace � ! Area <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Pump Inspection By Date <br /> Destruction Inspection By <br /> Date Comments:_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED C8EC1(11CASH REC ED BY OATE PERMITISERVICE REQUEST ISUMBER JUV010E <br /> r <br /> (� D <br />