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APPLICATION FOR WEWPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> 909-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GIgMEE M TrOrkstS) <br /> APPLICATION EB IEIIE BY MADE TO THE BAN"AWN COUNTY FOR A PER I E TO CONSTRUCT AND/OR INSTALL THE WORC DESCRIBED.T,HIB AFPLICATON IB MADE N COMPLIANCE WITH BAN � <br /> "AWN COUNTY DEVELOPMENT TREE.CHAPTER 81115.7 AND THE STANDARDS OF SAN"AWN COUNTY PUBLIC(HEALTH BERVICES.ENVIRONMENTAL HEALTH DMOMN, <br /> JOBAOOIEBBNRAP1020763 E. Harney Lane C,n. Lodi PARCEL RQUARM <br /> .,,.Robert Indelicato ADDRESS 16930 E, Comstock Rd. L_,gAgn <br /> CONTRACTORPurviance Drillers , Inc ADDREBSPOBox 64 ,Linden m, 377923PIONE/ 887-3554 <br /> BUB CONTRACTOR ApOIEeS LIC/ PHONE• <br /> TYPE OF WELLMUNIF. 19 NEW WELL ❑ REPLACEMENT WELL ❑ MONrrOnNa WELL/ ❑ OTHER <br /> ❑ MBTAUATON ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTMCTON WELL F ✓ <br /> ❑Nwn❑Rw.lr H.I. DEPTH FUMP BET—R. FIRST WATER LEVEL O <br /> aYEE OF FIIMPI <br /> ❑ OVTLF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOR BORING e <br /> ❑Ot"Ammw <br /> INtEADED VFF TTTpTRE OF SLL CONSTRLICTON SPECIFICATIONS A <br /> ❑ INDUSTRIAL W OPEN BOTTOM DIA.OF WELL EXCAVATION 19 CIA.OF CONDUCTOR CA91NO n/a p <br /> ❑ DOMESTIC,ORIVATE El GRAVEL PACKMIZE TYFEOFCASHNOAHEEE/PVC steel DIA.OF WELL CASINO OO12-374 <br /> p (\ \ <br /> Cl mmmuteCIPAL ❑DISVFN DEMN Of GROUT SEAL 280 SPECIFICATION . 188 <br /> fl O <br /> ® iRRIOATIONlAO ❑OTHER GROUT BEM INSTALLED BY PDI OIDT BRAND NAME E <br /> ❑ MOMTORNO OMUT SEAL INtUma: 12 Yr [IN. CONCRETE PEDESTAL BY DNLLER:❑Yom 0N 5 <br /> AIPIOX.DFPTN 500 LOCKING CHESTER BOX/STOVEPIPE S <br /> PIOIOSFD COMSTIIVCRONIDRWNO METHOD: MUD ROTARY X AIR ADTAFTY AUGER GABLE OTHER IW <br /> I HERBY CERTIFY THAT I HAVE PREPARED THIS APPICATION AND THAT THE WOW WILL BE DONE M ACCORDANCE WITH BAN"AWN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO (�'( <br /> REOWITIONB OF THE SAN JOACKAN COUNTY. HOME OWNER OR LICENSED AGENT'S 910HATUM CERTIFIER THE FOLMWE IO:'I CERTIFY THAT 1N THE PPEORMANCE Of THE WORK TOR W N <br /> THIS PERMIT IS ISSUED.104M NOT EMPLOY RRSONS SUBJECT TO WORWAN'S COMPNSATMN LAWS OF CALIFORNIA! CONTMOTOFVS HIM"OR SVBLONTMCTNO SIONATURE CERESIEB <br /> TIE FOU. I CET M TIE RROnvANCE OF THE WORE FOR WHICH THIS rEmm HS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION"We OF <br /> CAUF A.' T e LL EA HUURS IN ADVANCE FOR ALL REQUIRED HNSMINA1E AT IOOeI 44111.Re13. COMPETE DMWINO AT LOWER AREA PHOVIOED. <br /> , _ „,.—Corporate Secretary D.,, 8/17/98 <br /> PLOT RAN Sam,to Scoop Rao. 1. <br /> I. NAMES OF BTBEETS OR ROADS NEARBT TO OR BOUNCING THE RDPEREY. e. LOCATION OF(HOUSE REWAOE DISPOSAL SYSTEM On P CIMSM <br /> i. OVTLRIE OF THE PDFERTYY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWADE DISPOSAL SYSTEMS. <br /> J. WoMNSONED ONTUNFB AND LOCATION OF ALL EXISTRq AND PI OMSED E. LOCATION OF WELLS WITMN MdU9 OF ONE HUNDRD FIFTY FT. <br /> STRUCTURER,NCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE P10PRTY OR ADJOINNO PDMITTY. <br /> �V— <br /> ASCI ' <br /> PAYMENT <br /> AUG 2'1 1998 <br /> SAN JOAUU1N'COUN FY <br /> -PUBLIC14FALTHSERVICES <br /> - — - ENVIRE7NMENTAL HEALTH DIVISION <br /> DRINA RTMENT USE ONLY <br /> /.ppft.lbn AeaeFtaR By DFIF A­ 7 I Z/ <br /> �T <br /> roan Mpcllm er A In.poaHH.n By Ow. <br /> O�br.alan Irwn.el,m B• OHs <br /> Cammo-.r' <br /> ACCOVNTINO ONLY: ND/ FACT <br /> IE CODES FEE INFO AMOUNT ADMITTEDC /CAS” RECEIVED BY DATE INOWITIZERVICE REOUEST NUMBER INVOICE <br /> o� <br /> Pub Health SON.-Envifo. 173(1/97) <br />