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Date 005 <br />Area 6e/ <br />Date <br />DEPARTMENT USE ONLY <br />Date Pump Inspection By <br />Application Accepted By <br />Grout inspection By <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468.3420 <br />KI #20-3882-01.E01 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# CITY PARCEL SIZE/APN# <br />911 Clarane Street Stockton <br />OWNER'S NAME Jack Fuller ADDRESS 6635 Gribsby Pl. ,Stkn,CA pHoNE# 478-3040 <br />CONTRACTOR Kleinfelder/Spectrum <br />ADDRESS 2365 Wigwam, Stkn.91,g,9 5 <br />PHONE #465-1345 <br />SUB CONTRACTOR ADDRESS LICa PHONE a <br />TYPE OF WELUPUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL a 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # <br /> 0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 4 SOIL BORING two <br />0 DESTRUCTION: '..."0 -.....„ <br />......... INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />" 0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION 6 DIA. OF CONDUCTOR CASING <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />MONITORING <br />APPROX. DEPTH <br /> 15' <br />PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY <br />TYPE OF CASING/STEEUPVC DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />GROUT SEAL PUMPED: El Yes )4 No CONCRETE PEDESTAL BY DRILLER: El Yes Me <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY X AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091441S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />• <br />Sipped X --1-1 Date <br />I V") 1 Title <br />T PLAN (Drew to Scale) Scale **. " to <br />1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />2 OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />"1-R1117T1IFICR Ihrl I iniun CCWFRF11 AREAS SUCH AS PATIOS DRIVEWAYS. AND WALKS. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />RECE1 VED <br /> JUL 1 3 1995 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Destruction Inspection By Date <br />Comments: <br />ACCOUNTING ONLY: AID# FACa <br />STeM)(7/r/C &._1 <br />PE CODES FEE INFO AMOUNT REMITTED CHECKVCASH RECEIVED BY PERMIT/SERVICE REQUEST NUMBER INVOICE D7 <br />E 5R LC)Pte ie f,),.