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APPLICATION FOR WELLIPUMP PERMIT
<br /> (eivSAN JOAQUIN COUNTY PUBLIC HEALTH SERY�f PAYMENT
<br /> ENVIRONMENTAL HEALTH DIVISIONip RECEIVED
<br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, C'A 95201-388
<br /> (209) 468.3420 I1 A'!' 1 0 19,16
<br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO DATE ISSUED PUB1LICi�'AL H IN COUNTY
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<br /> APPLICATION (Complete in Triplicetel 'I ENVIRONMENTAL KOH PIVOON,APPLICATION 1S HERE BY MADE TO THE SAM JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT MDMA 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 ADDRESSIOR APN#' 900 1 /2 Vi cotr Rd. CITY Lodi PARCEL SIZEJAPN4'Q -�
<br /> OWNER'S NAME John Teres ADDRESS P•O•Box 1 S7 0 r Lodi 95241
<br /> PHONE# }
<br /> CONTRACTOR Purviance Drillers Inc, ADDAESSP.O.Box 64LLinderlic,, 377923 PHONEN 887-3554 ]Y
<br /> SUB CONTRACTOR ADDRESS (I iE LCA' PHONE I
<br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ i�
<br /> ', ❑ OTHER
<br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR I{ 13 VAPOR EXTRACTION WELL
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<br /> (TYPE OF PUMP]
<br /> 13 Now El Repair H.P. DEPTH PUMP SET FT. - FIRST WATER LEVEL 0
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<br /> 0OUT-0F•SERVICE WELL ❑ GEOPHYSICAL WELL A' � ❑ SOIL BORING
<br /> DESTAucTIoN: remove petrolum prod from water, pump 9sack sand and cement from bottom.
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<br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONe
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<br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION 'r DIA.OF CONDUCTOR CASING
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<br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE Of CASINGISTEELIPVC iI iI DIA.OF WELL CASING
<br /> ❑ PUBLIC/MUNICIPAL 11p DRIVEN DEPTH OF GROUT SEAL (f �� SPECIFICATION R
<br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY � :A GROUT BRAND NAME E
<br /> ❑ MONITORING
<br /> 140 GROUT SEAL PUMPED: ❑Yea ❑No } CONCRETE PEDESTAL BY DRILLER:❑Yep ❑No S
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<br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE :j S l
<br /> PROPOSED CONSTRUCT10N/pWLLING METHOD; MUD ROTARY
<br /> AIR ROTARY AUGER ihCABLE 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: �1 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 CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES G
<br /> THE FO "I CEATIIY PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iS ISSUED,I SHALL EMPLOY Pt;RBONS SUBJECT TO WORgNAN'8 COMPENSATION LAWS OF 7
<br /> C RNIA.' TH PPLICAN M CALL NOURB IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120e!4eB3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. '
<br /> Slpned Title Corporate Secretary D,Ye 5
<br /> /10/96
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<br /> PLOT PLAN{prow to Sule1 Scale 'to �� � I
<br /> 1. NAMES OF STREETS OR ROADS NEAREST TD OR BOUNDING THE PROPERTY. l`4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED '
<br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS,
<br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED i b. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr.
<br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY,
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<br /> DEPARTMENT USE ONLY
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<br /> Application Accepted By ! page L3. A Area
<br /> Grout Inspection By Date Pump Inspection By Date .
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<br /> Destruction Inspection By �r I� � Date
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<br /> Cemmenu• A&,&f&5 IM UkeAt 4IN
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<br /> ACCOUNTING ONLY: AIDN FACA'
<br /> PE CODES FEE INFO LTOUNT REMITTED CHECK#ICASH RECEIVED BY DATE Ip PERIMITISERVICE REQUEST NUMSM INVOICE
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