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COL <br />OWNER'S NAME <br />CONTRACTOR jzvxjp.ADDRESS PHONE • <br />SUB CONTRACTOR ADDRESS UC* PHONE f <br />NEW WELL (CEMENT WELL <br />REPAIR <br />H.P.DEPTH PUMP SET,FT.FIRST WATER LEVEL O <br />OUT^F SERVICE WELL B <br />L^. <br />INTENpED USE <br />A <br />DIA. OF CONDUCTOR CASINO D <br />TYPE OF CASINO/STEEL/PVC DIA. OF WELL CASINO D <br />DEPTH OF GROUT SEAL SPECIFICATION R <br />E <br />Ono S <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/OWLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />REPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO <br />**•Signed XI Title <br />’ to <br />4 <br />DEPARTMENT USE ONLY <br />Application Accepted By_ <br />Grout Inspection By Date Pump Inspection 0y_Data <br />Deatruetlen Inspection By Data <br />< sCommerce: <br />ACCOUNTING ONLY:AID,FACJ <br />FEE INFO AMOUNT REMITTED RECSVED BY DATE PERMIT/SERV1CE REQUEST NUMBER INVOICE <br />1 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: Yaa No <br />PLOT PLAN (Draw to Scale) Scala <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />I HEREBY CERTIF <br />REGULATIONSjtfi <br />THIS PERMIT/S II <br />THE FOLLO) <br />CAUFORNM <br />i • . <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM Ofl PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />5. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />M <br />...j...i <br />c <br />£ <br />c <br />WELL SYSTEM REPAIR <br />. 7 (0 <br />(j^CIIgpXflCASH j <br />I -U -TCTCy'r- I <br />DESTRUCTION: <br />> <br />PE CODES <br />b <br />(TYPE OF PUMP) <br />TYPE OF WELL <br />O OPEN BOTTOM <br />O GRAVEL PACK/SIZE <br />D DRIVEN <br />DOTHER <br />^>✓0 Cf> C <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: Yo. <br />CITY <br />ADDRESS <br />Box IA Z7 <br />:D, I SHALL <br />ING: ’J CERTIFY/ <br />’ THE ApPUCA<T J <br />TYPE OF WELL/PUMP: <br /> INSTALLATION <br />D New D Reoelr <br />--------------------------------------------------------------------------------— "________ ______ ____ ft <br />8 S'^NATURE CERTIFIES THE FOLLOWING: ’I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ‘ <br /> CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES Jt <br />Pt OY PERRTlNfl fttlR IPPT m WnBrusiPa . ..... '' <br />Lt, i tH a-1 <br />JOB ADDRESS/OR APNf O(Q • <br />iSf <br />feel-lX HT <br /> GEOPHYSICAL WELL • SOIL BORING <br />. c^/oiri'v\a.-(-aA Mtg-l-t_______ <br />-- I I I 5.3 AND DIE STANDARDS OF SAN JO. <br />£1 <br />D OTHER <br /> VAPOR EXTRACTION WELL • <br />D RFj <br />UJ INDUSTRIAL <br /> ngMESTIC/PRIVATE <br />H^PUBUC/MUNICIPAL <br /> IRRIGATION/AG <br /> MONITORING <br />CF THE SAN JOAQUIN COUNTY. HOME OWNER OR, <br />/oT EMPLOY PERSON^ 8UBJEC <br />|AT IN THEj^RFORMM^q/e^ <br />IUST CAlV/24 <br />D MONITORING WELL * <br /> CROSS-CONNEt <br />, D OUT^r SERVICE WEL <br />(My <^4~/p£cccv?) kxZL <br />^TC^WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.’ •— —------------------------------------------ <br />I5^'VOBK f2W,W"ILI1 llllB~LERya) I® ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />JJJCE FOR AL| REQUIRED INSPECTIONS AT I2O«^4^JAJS.^COMPLFTE DRAWING AT LOWER AREA PROVIDED. <br /> Det, <br />IUSWY DU8LIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION <br />L /<_ y) PARCEL SIZE/APNf <br />^vv\ o (f <br />/fc 2. "/ 3 PHONE * <br />■ * s <br />; '' '■................’■ ■ <br />j. :■■■ <br />r ..i' <br />:.......j <br />’ices: <br />± + <br />.. : 2 <br />• ■ * i........' ' ■ ? ■■■’ f* : <br />r'-SLiC