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TYPE Of WELUPUMP. ❑ NEW WELL ❑ R 'M WELL ❑ MONROPNO WELL, ❑ OTHER ❑ MBTAIUtION ❑ REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAIOR EXTRACTION WELL I YPE ❑- ITw• 1:1mllp� H.P. 1 - OF""PUMP eEd;—LoFT, FIRST WATER LEVEL OF&I0 IT 11E,R.�VYi,LpE L� ❑ OWT F-KRVIOE WELL ❑ GEOPHYSICAL WELL, ❑ colt BORING B ❑DESTRUCTION' INTENDED UFETYPE OF W CONETRIlCt10N EPECIfIMo.. A ❑ INDUS'MAt ❑OrEm BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p XDOMESTICR VATE ❑GRAVEL PACKISIZE TYPE OF CASINOIBTETLR DIA.OF WELL CASINO p ❑ PUBLICMVHICIPAt ❑MWN OEPTN OF GROUT REAL SPECIFICATION A ❑ IMOATIONIAO ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROW REAL PUMIRO: ❑V. 11 N. CONCRETE T40ST EAL BY OEIL VER:❑Y- C]N. 5 APPIOX,OEF'FH ISS... LOCKINO CHESTER BOXWOVE PPE_ S PROPOSED COMST1RlKTIONR*N11O0 METE DMUM ROTARFY_AIR ROTANY AUCER CABLE OTHER I HEREBY CERTIFY THAT I IIAW PREPARED THIN APPLlCAT10N AND THAT THE VMW V* BE DONE M ACCORDANCE WITH SMI JOAODN COUNTY ORDINANCES.STATE LAWS.AND RULES AND MOULAMNS OF THE BAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT-S MONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT INPEWORMANCE Of THE V W MR VMCH THEN PERMN IB ISSUED,191 1LL NOT EMPLOY PERSONS SUBJECT TO W0NXIMAN'111 COMPENSATION LAWS OF CALNOEMA.' CONTRACTOR'*MR OR SUB-CONTRACTNIU BKMATUPE CERTIFIES THE FOLLONINO: •1 CERTIFY THAT M THE MR MANCE OF THE VMRIK FOR NMICH THIS PERMS IS ISBUES.1 SHALL EMPOY PERSONS MCT TO WOROAAN'*COMPENSATION"W.OF THIN VS CALIFORNIA.- TIT CALL U U IN AOVANC 1 PORI ALL STOWED INS MR*AT IJR*1 4*4.1.XS. COMPETE DRAWIrIAT LOWER AMA POVIO[O. SI.-w x PLOT MN RTrw I.S..I.I S..I. •M 1. NAMES OF RTREFTS OR ROADS NEAREST TO OR BOINIDNO THE PRDVERTY. L. LOCATION OF MUM SEWAGE LXBPoSAL SYSTEM OR PROMFIEO t. OUTLNLF OF'HE FTOP ITY•OPMO DMENMUNS AND NORTH DOECTION. EXPANSION OF SEWAGE DSPOSM SY*TFM*. T. DIMENSIONED OWLRES AND LOCATION OF ML EXISTING AND PROPOSED S. LOCATION Of WELLS VNPIM RADMS OF ONE NIMOPO FIFTY T. STRUCTUIIEN,SICL IDINO COVERED AREAS SUCH AS PATIOS.DMVEWAYS,AND WALKS. ON THE POVERTY OR AF,JCHMM,FROPEE,Fy. 1 � Re LI) z"NVUFL J � �DFPMT T USE ONLY AVPS..Ibn A.,l.d By ACCOUNTING ONLY: AID, FAC# PE CODES FEE INTO AMOUNT REMITTED CHEC"tOA914 RECEIVED NY DATE POVAITISIERVICE REQUEST NPASER INVOICE DIto -f aas D.I, u.elx.'C.- -P-im 17a/1 ROT _ ..