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0 DOMESTICIPPoVATE 0 GRAVEL PACKISVE TYPE OF CASINGISTEEUPVC 4 DIA.Of WELL CASING u <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN ` � <br /> DEPTH OF GROUT SEAL <br /> "tSPECIFICATiON R <br /> ❑ ERRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY -_ 'i AROUT BRAND NAME <br /> © MONITORING GROUT SEAL PUMPED: ❑Yes No 'CONCRETE PEDESTAL BY DRILLER:❑Ys 0N S. <br /> _ LOCKING CHESTER.BOXISTOVE PIPE S <br /> APPROX.DEPTH - ' <br /> PROPOSED CONSTRUCTIONIDRIWNO.-NtETHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> i <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACT"SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATIONLAWS OF <br /> CALIFORNIA' THE APPLICANT MUST CALL 24 HOUfta IN ADVANCE FOR ALL REQUIRED I,N[SPECTION&AT(209)4683423• COMPLETE DRAWING AT LOWER AREA PROVIDED- <br /> Title _ <br /> Signed X <br /> PLOT PLAN [Draw to Sade)Scale "to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.', <br /> r 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS: ` ON THE PROPERTY DR ADJOINING PROPERTY."... ... .. .. -..... <br />` <br /> .:.... ..... .: ....... .. <br /> .,.. <br /> DEPARTMENT USE ONLY J i•' -r,DI <br /> Date r ` Area <br /> / L O,P <br /> Application Accepted By <br /> �� y . <br /> Grout Inspection By �f'!C_ - _ Data O �� Pump Inspection By _ - Date - <br /> Date <br /> Destruction inspection By <br /> F ! ,c <br /> Comments' r ICl <br /> Fk <br /> ACCOUNT[NO ONLY: AID# FACN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKN ASH RECEIVED By DATE PERMITISERVICE REQUEST NUMBER INVOICE .;". <br /> vo r r fit it. �1 a r�4; <br /> . ;i <br />