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(TYPE OF PUMPI ` <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL7 SOIL BORING_� B <br /> ❑DESTRUCTION: <br /> 4 IN 1 Ei1DED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& / A <br /> ElC <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION (n— r \ DIA.OF CONDUCTOR CASINO Z A O <br /> ❑ DOMESTIC/PRIVATE ❑13RAVEL PACK/SIZE TYPE OF CASING/STEEL VC DIA.OF WELL CASINO GIL D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORINGJ I GROUT SEAL PUMPED: ElY- El N. CONCRETE PEDESTAL BY DFULLER:❑ ❑Yw No S <br /> APPROX.DEPTH ',7 LOCKING CHESTER BOX/STOVE PIPE 7 -- 5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WIIICH <br /> THIS PERMIT IB ISSUED,1 SIIALL NOT OY PERSON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNG OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: CERTIFY TH I IE bRM ANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T 771 ALL `)R&INADVANCE FOR ALL REOURFD INS►ECTIONS AT 12011)46&3423. COMPLETE DRAWING AT LOWER AREA PROVIiBlpnedX � Tltls / �2ni -�siv�✓/ Date <br /> PLOT PLAN IDr t.S-4.1 Scale 1. <br /> 1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR mo ro SED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WFTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ..:. - .. <br /> . ...... .... .. ......: .......: i... .. . <br /> 1 <br /> AL <br /> . <br /> t DEPARTMENT USE ONLY Y <br /> APPlloellnn Ac.r..t n.l Py '1 � Dale " '" Ar.e <br /> nr t I—P-11—By 1 Dele P Inrv.cli.n By Dele <br /> O.nln.c U.n Ina 11—By D.t.yry— <br /> cnmm.,t. L <br /> (.� G <br /> r' <br /> ACCOUNTING ONLY: AID/ FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI SH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER IN CE <br /> '(17-8D <br /> IF <br /> S <br /> Pub.Health Serv.-Enviro.173(1/97) <br />