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Cos* . <br /> APPLICATION FOR WELL/PUMP PERMIT _ 6 oov V r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 r N <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) .FL��_ <br /> APPLICATION IS$41M BY MADE TO THE SAN JOAOUN COUNTY FOR A FEIOAIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESC WRED.THIS APPLICATION IB MADE IN COMPLIANCE WAIT RAN <br /> JOAMN!COUNTY DEVELOPMENT TALE,CHAPTEII 9-1115.3 AND THE STANDARD@ OF SAN"AMIN COUNTY MOM HEALTH SERVICES,ENWMNMEMAL HEALTH DMBIUN. <br /> JOBADDIWOMRAPN1 18621 N. Hwy 99 cm. Lodi PARCEL SIZE/AM0 <br /> owNEReNAME Calvary Bible Church ADOREBO P.O.Box. 1503, Lodi,Ca PHOWe <br /> DoMRACTORPurviance Drillers, Inc. ADDRESS P.O. Box 64 ,Lincon 3779�4NEF887-3554 <br /> BUe COMPACTOR ADDRESS LIC# PHONE I <br /> TYPE OF WELl/PUMP: ® NEW WELL ❑ wvRACEe E WELL ❑ MONTTORIM WELL F ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTPACTMN WELL F <br /> Submer IM w 0R.Pdr N.P. 7 1 2 DEPTH PUMP SETT 30FT. FIRST WATER LEVEL O <br /> HYPE OF PUMPI <br /> ❑ OM-00.SERVICE WELL ❑ GEOPHYSICAL WELL S ❑ WNL SOWNO <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INUUSTWAL ®OPEN DOTTOM DIA.OF WELL EXCAVATION 14 3/4 DA.OF CONDUCTOR CASINO O n/ 0 <br /> 11D0MESTWMnJVATE ❑OPAVELPACK/SIZE TYMOFCASINGMTEEUPYC steel DA.OF WELL CASINO 8 5/8 0 <br /> ® MBLICIMUNICIPAL ❑OWVEN OEPTII OF OMUT SEAL 2201 BIECIFICATION . 156 R <br /> ❑ IRWOATIONIAO ❑OTHER SMUT SEAL INSTALLED NY PDI OWMT BRAND NAME E <br /> ❑ MOMTOWNO GROUT SEAL PUMPED: ®Y« 0H CONCRETEMDESTALSYDRIU-MOY« ❑Ne 5 <br /> APPROX.DEPTH 300 LOCKRM CHESTER BOXISTOW PIPE S <br /> PROMSM CONSTRUCTIONIOWLUNO METMD: MUD ROTARY x AIR ROTARY AUOER CABLE OTHER <br /> I HERESY CERTIFY TIIAT I HAVE PREPARED THIN APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE PATH BAN"AMIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR MENSEO AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TILE WORC FOR WHICH <br /> THIS PENIA It ISSUED,I SHALL NOT �RRMNB SUBJECT TO WORIIMAN'S COMrtNSAHON LAWS OF CALRORMA.' COMPACTOR'S HIWND OR NUB{OMRACTINO NIONATUM CERTIFIES <br /> TW FOLLOWS@!" CERTIFY T IN T1 E 1 ASCE OF TW WORK FOR WHICH THIS RRMTT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO YIORIGMAN'S COMPENSAAON LAWS OF <br /> CAUF RN _ TILE AMM C 24I U1@ IN ADVANCE FOR ALL REGUINm INSRECTIONI AT I]Del.p- ". COMRETE DMWINO AT LOWER AREA FMNDED. <br /> BIFn.e%� /,(/,F�/-rv'-z< -F„ Th'. Corporate Secretary D„]/13/99 <br /> MOT RAR Rk.w to%0.1 Bad. to <br /> 1. NAMEB OF STREETS OR MAOB NEAREST TO OR BOUNDNO THE FMIPRTY. e. LOCATION OF HOUSE SEWAGE DBMSAL SYSTEM OR WIOIOSEU <br /> 2, OUTLINE OF THE PMKE .GIVING DMENSRONS ANO NORTH DIMCTMN. EXPANSION OF SEWAGE DBMM SYSTEMS. <br /> J. DIMENNMOWD OMMFS ANO LOCATION OF ALL EXIBTINO AND P MEED e, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE FROMFITY On ADJOINBIO FTIOPERTY. <br /> }} y L <br /> PHASE 2 <br /> 1 <br /> 'Do <br /> nusI `-. FUTURE - L <br /> OFFICES TP s� <br /> EDUCATION <br /> 312.000 SF I-- LAVI i <br /> 7 R700'0” �- <br /> .,C <br /> 159,0 }/8,.' _.L. <br /> 0 'p:: �_�.1. ' 358 <br /> o- TYP I1 11 <br /> I <br /> PHASE I <br /> WORSHIP e <br /> EDUCATI N d 4 <br /> 4,343 Sp e <br /> p UTt <br /> ARF <br /> a 1a17 5F <br /> 6 1 IJO'0,•. 4 II G c'. 27C <br /> h 13 I � 6 6 LAINT - 77P <br /> DEPARTMENT USE ONLY <br /> ASP <br /> Alleod eY_._ /T`- '�.Y A� D.I. <br /> PP .lbn <br /> n'"M«eNn Br � O.I. R p In.P«nen By �F� DD.. <br /> G«InNtIM IrwP«Nen <br /> By Oe1• PAY,A R N. <br /> ACCOUNTING ONLY: AIDS FACS <br /> PE CODES FEE IWO AMOUNT REMITTED CHEC"MASH RECIRM SY DATE PB TISMMCE RFG IN <br /> pt3y P-9 <br /> d <br /> Pub Health Serv.-EnViro.173(1/97) <br />