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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE �. <br /> ENVIRONMENTAL HEALTH DIVISION A� <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICEmpMu M TrIpReEtEI <br /> APRICATION IS"ERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDA.INSTALL THE VAR(DESCRIBED.THIS APPLICATION 10 MADE IN COMPLIANCE ATTH SAN <br /> JOAOUIN COUNTY DEVELOPMENT YULE.CHAPTER 8-111 B.'AND THE STANDARDS OF SAN"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDREBwRASNE 18621 N. Hwy 99 Cin, Lodi PARCEL RQUAFNI <br /> .,,,.—Calvary Bible Church AWIEBNP.O.Box 1503, Lodi, Ca PHONEI <br /> CONTRACTOR Purviance Drillers, Inc. ADORES. P.O.Box 64 ,Lindav 377923RIIOWI 887-3554 <br /> SUBCONTRACTOR ADDRESS MR PHONEI <br /> TYPE OF MU/PUMP IBJ NEW WELt ❑ REMACENTINT VIELL ❑ MONRORINO WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACT I J <br /> ❑NM❑REPMI N.P. DEPTH RUMP SET_FT. F ATER LEVEL O <br /> OYPE OF PUMPI <br /> ❑ OWOFBERVOE WELL ❑ GEOMY91CAL WELL I ❑ SOIL RONNO N <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL y0 OPEN BOTTOM SIA.OF WELL EXCAVATION Z Z 11 A.OF CONDUCTOR CASINO n/a O <br /> ® DOMESTICIAVVATE ❑GRAVEL PACK/SIZE TYPEOFCASINO/STEEt/PVC -T S to 1 A.OF WELL CASINO1611 O <br /> ❑ PUNl1CAAUNICIPAt ❑DRIVEN DEPTH OF GROUT DEAL ��e I S14CIFICATION . 250 R <br /> ❑ IFJVOATION/AO ❑OTHER GROUT SEAL INVALLEDFT A�BLLY PDI GROUT BRAND NAME E <br /> ❑ MONITORING OMUT SEAL PUMPED: [2Y. [IN. CONCRETE PEDESTAL BY DRIMEM❑Ym ON. 5 <br /> APPROX.DEPTH 17 5 1 LOCKING CHESTER SOXWOVE RPE 5 <br /> PROPOSED CONSTRUCHONImSWNO METHOD: MUD ROTARY X AIR ROTARY AMER_CABLE OTHER <br /> I HERERY CERTIFY THAT I HAVE PREPARED THIN APR/CATION AND THAT THE MW WILL BE DONE M ACCORDANCE WITH BAH"AMIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN MAmNN COUNTY. NOME OWNER OR MINSED AOEW'B BIONATURE CEW WES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICII <br /> THIN PERMIT IB ISSUED.1 MULL NOT EMPLOY PERSONS SUB.IECT TO WORKMAN'S COMPENNARON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> TI OMA 1 CERTIFY T ATM PERFORMANCE OF TIRE WOR(FOO WHICH THIS MRAIR IN ISSUED.I SHALL EMPLOY PERSONS NUSLIECT TO WORKMAN'S COMPENNAHON LAWN OF <br /> C M <br /> ORA.' APP11 T ET CA NOME IN AMAMI FOR ALL RMUIIM INSPECTIONS AT Lh N140-MEI. COMPETE ORAWING AT LOWER ARTA PROVIDED. <br /> TRI. Corporate Secretary D„F 7/13/99 <br /> ROT RAN RN.,.R Se,l.l SeMS •I. <br /> I. NAMES OF SNEETN OR ROADS WARIEST TO OR BOUNOMO TW PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSED <br /> ]. OW LINE Of TIRE P110PERTY,OIVNIO DIMENSIONS ANO NGRTH DIi1ECTON. EXPANSION OF SEWAGE DUPoNILL SYSTEMS. <br /> D. DIMENSIONED OWLIMES AND LOCATION Of ALL EXINTING AND PROPOSED S. LOCATION OF MILE WITHIN RADIUS OF ONE HUNDRED FIFTY P. <br /> STRUCTURES,RCLUDINO COVERED AREJLE SUCH AN PATIOS.DRVEVWAYE,AND WAUIS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> p 'iI V" •0. ay.rill ..�oJ <br /> PHASE I -.1.6• <br /> j WORSHIP 6.. <br /> EDU <br /> CATI <br /> O �. r�24,343 SF I D <br /> UT( <br /> O.- yB.D ARA1 <br /> D: 197 s <br /> I � <br /> i I <br /> 6 LA4,{y I TYP <br /> I _ Rzp J.0 AL <br /> 4 Roc <br /> 140.0" <br /> 4 ® c <br /> t'qzC .. I - ® ' qf�PEi1fED <br /> Trp J lam <br /> 3 <br /> ,TIP A OIN COUNfV`, <br /> K 1� c EfyVl LTH SERVICES <br /> 4 X) m AL HEA <br /> o LTH DIVISIO <br /> w <br /> D"AA MEHT USX ONLY <br /> 01e,A H..Puelbn Sr Om PMne Imomtlen My DMS <br /> n«R�tuen lmn«uen Nr// DEI. <br /> ACCOUNTING ONLY: ANN' FACS <br /> PE CODES FEE IWO AMOUNT MMITIED EIEC AASH RECEIVED SY DATE PEIKRTISEIIVICE REQUEST NUMEEIL INVOICE <br />