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APPLICATION FOR WELLIPUMP PERMITkmoJ i JOAQUIN COUNTY PUBLIC HEALTH SERVICE _ ENVIRONMENTAL HEALTH DIVISION KI 020-3882-01.E01 P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4883420 NON•REFUNDABI.E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i n*bft in Tr4Gean1 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PQWtIT TO CONSTRUCT ANDJOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDAESSMR A~ 911 Clarane Street CITY Stockton PARCELGMAPN+I OWNER'S NAME Jack Fuller ADDRE,,6635 Gri bsby Pl..,Stkn,CA - PHONE#478-3040 cowRAcroR Kleinfelder/Spectrum ADDRESS 2355 Wigwam,Stkn.9j2Q5 PHDNEN►455-1345 SUB CONTRACTOR ADDRESS LIG' PHONE I TYPE OF WEl11PUMP. ❑ NEW WELL ❑ REPLACFATENT WELL ❑ MONITORING WELL P ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR VaAACTION WELL I J ❑w.❑%w& H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d (TYPE OF PUMP) ❑ OU'r-0F-SFJ&=WELL ❑ GEOPHYSICAL WELL I � SOIL BORING two 8 ❑DEbTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A Cf� ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION V DIA.OF CONDUCTOR CASING — D ❑ DOMESTIwmvATE ❑GRAVEL PA=mazE TYPE OF CAStNGMULIPVC F DIA.OF WELL CASING — D ❑ PUBLIGIMUNIMPAL ❑DRIVEN DEPTH OF GROUT SEAL — SPECIFICATION — R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY �I GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y./yp N. CONCRETE PEDESTAL BY ENO IIER ❑Y.. SIN. S t APPROX.pEPTH 15 LOCKING CHESTER BOX/s'1'OVE RPE 5 PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY x AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERIAIT IS ISSUED,L SHALL NOT EMPLOY PERSONS SUBJECTTO WOPWAAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR$HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES _ THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT LWW 406-34=. COMPLETE DRAWING AT LOWER AREA PROVIDED. frond X --( Two 'Sfz�� t�7L� Date '71 t 3f�►�� PUN LOraw to Scwl s..Ie •:o 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROP9SEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ErMICTURM.INT'r r OINt.IOV09M AREAS SUCH AS PATIDIi' DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY- ... _ ............... ..i............ .. .. .. .. - .................................................. ......................7 ........ ....... ...... ..... ...... ..RECEIV ........... ......E......... ................... ... ...... ..... ..d. ...- Uzi ; ... ..:. ................. ............ ................................................ I' ................................. A.................... ..... ................... yj ..... ...................... .................................. Ux.. ........ - - .. .. .. .- s .., ... _ i L . DEPARTMENT USE ONLY 9 Application Accepted BY pate l`f !� Ane Grom Irrpaatlan By Date Pump Inepeetbn By Data Destruction Impaction By J ,� Commons: 2 .�t�K- Y�'� QIC�- ` ACCOUNTING ONLY: ALDI FAG/ PE CODES FEE INFO AMOUNT RNMTTTED CHMK#ICASH RECEIVED BY DATV PEIYMRISERVtCE REOUEJIT NUMBt3t INVOICE