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APPLICATION FOR WELL/PUMP 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 /> r . <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete M TTIpReetel <br /> AFTEMAHON IS INK BY MADE TO THE BAN JOAOUIH COUNTY FOR A PERMIT TO CONBTAMT AROMA INSTALL THE YORK DESCRIBED.71119 AFFTICATION IB MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STANDARDS Of BAN MACU I COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOMIAMORAPM# 18621 N. Hwy 99 CITY' Lodi PARCELBIZUAM# <br /> ,.,,,.— Calvary Bible Church AOCIESBP.O.Box 1503, Lodi , Ca p„ONT# <br /> CONTRACTOR Purviance Drillers, Inc. ADDRESS P.O.Box 64 ,Lindem 377923PHom# 887-3554 <br /> BUB CONTRACTOR ADCIESS ME PHONE I <br /> TYPE OF WELLMP .. ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N.W❑R.Pef Hp. DEPTH PUMP SFT_FT. FIRST WATER LEVEL O <br /> R YFE OF PUMP( <br /> ❑ OVT#-SERVIOE WELL ❑ GEOPLIv91cAL WELL# ❑ SON.ROPoNG B <br /> ❑DESTRUCTION: <br /> INTENDED USE CONSTRUCTION SPECIFICATIONS ^1 A <br /> ❑ INDUSTRIALOPEN BOTTOM DIA.OF WELL EXCAVATION ILEI A. CONDUCTOR CASINO n/a O <br /> ® DOMEBTICIRIIVATE ❑GRAVEL PACK ZE TYPE OF CASING/8TEEIA'VC ss to A.OF WELL CASING 1 611 O <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ,/C'e 1 N�o SPECIFICATION . 250 R <br /> ❑ IRWOATION/AG ❑OTHER GROUT SEAL INSTALLED,�BB1Y, PDI GROUT BRAND NAME E <br /> R <br /> ❑ MONONNG GROUT SEAL PUMPED: IdY. 0 H CONCRETE PMEBTAL BY MILLER:❑Yr 11 N. S <br /> APPROX.DEPTH 3 7 5 1 LOCKING CHESTER SOXJSTOVE RPE S <br /> PROPOSED CONSTRUCTION/NaWMO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> 1 HF9 BY CERTIFY THAT I HAW PREPAPEO THIS APPMATION ANO THAT THE WORK WILL BE DONE W ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES.STATE LAWS,AND BULLS ANO <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER CR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:•1 CERTIFY THAT IN THE PER09MANCE OF TINE WORK FOR WHICH <br /> THIS FERMAT IS ISSUED,1814ALL NOT EMPLOY PERSONS"ACT TO WORKMAN'$COMM(ATON LAWS OF CALIFORNIA.- CONTMCTOR'S HIRING OR SURCONTMCTING SIGNATURE CERTIFIES <br /> TIE,FOLI.MM_ 1 CERTIFY TKAAT IN PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' to=11T COIL a HOURS IN AMANCI FOR ALL REODUED INSMI IONS AT IZOel 4ee-MZS. COMPLETE DRAWING AT LOWER ATEA PROVIDED./ ���1� THIS Corporate Secretary D.I. 7/13/99 <br /> PLOT PLANT IO,w.le 9F,b1 Be.l. le <br /> 1. NAMES OF BTPEFTB OR ROADS NEAREST TO OR BOUNCING THE ROPERTY. 4. LOCATION OF HOUSE SEWAGE NOPOSAI.SYSTEM OR FOOMSED <br /> Z. OUTLINE OF THE PPOPLNTY,GIVING DIMENSIONS AND NORTH NRECTION. EXPANSION OF SEWAOE DBPOBAI SYSTEMS. <br /> D. DIMENSIONED OMLINT8 AND LOCATION OF ALL EXISTMO ANO PNOMSM e. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WAlXS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> v0� Y_1 _P <br /> PHASE <br /> WORSHIp <br /> 1 EDUCATI e q <br /> N ' <br /> c f <br /> U- i Y�B24,713. SF <br /> UT( <br /> 0'. b6 0 D. 197AR <br /> It <br /> A <br /> 1 JDb, q l O. c <br /> 41 I D I 79 6 LA�gT II-._ T <br /> YP <br /> RZO J•0.. 4 w <br /> D <br /> PAYMENT <br /> ♦-I(Y I ® c �R,E 6sEyIV ED ` <br /> TYP <br /> 3 P A < 1 .TYP S mM Ulry Q4UNTY!.. <br /> K N N 1 � ��- \ c E�VI LTH SEFNICEiS <br /> UPJ 4, ao <br /> w o <br /> OEPMTMENT USE ONLY �J <br /> APP11c.0—A.,HxI BY lam^"/ - / D.I. / A,., G'/L <br /> m.a Irwnnelbn Br D.I. ibnp L,.Pmae�ey De. <br /> Cemrnsw. —CAL.Gi/ - .'/i;,J.. "I n.�' li� "x. - . . -°��7 G-.. (S <� /oo-- 'L✓.�F L✓1 C+/1 /moi.JTZ <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HECK /CASH I RECEIVED■Y I DATE I PEIS.STNSERVICE MOUE/T NUMBER INVOICE <br /> Zi;, 4-61 5 f CAa �L' �— <br /> Pub Health SEN.-Enviro.173(1197) <br />