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F L1 pY311 F"N V r�cua•w,c...r.�r,vr _.._______.___. ._.._.. ' - <br /> ❑Naw❑Repair H.P. DEPTH PUMP SE-T___fT. Ft7 WATER LEVEL O <br /> (TYPE OF PUMP) <br /> r .-: S.ir d / `_ ❑ OUT-OF-&,..00E WELL <br /> ❑ GEOPHYSICAL WELL f <br /> ESTRUCTLON: -1 �i� Gt,�(iR�• m'a IrI <br /> !!!INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS '4 <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D <br /> 13DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELJPVC 'DIA.OF WELL CASING <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F. <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Ya ❑No CONCRETE SIAL BY DRILLER:❑Yea ❑No S' <br /> APPROX,DEPTH LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONJOWLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> - <br /> I HEREBY 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:'1 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 CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECTTO WOFIKMAN'S COMPUMATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 4206)408,422• COMPLETE DRAWING AT.LOWER AREA PROVIDED- <br /> Si Uned <br /> ROVIDED.SiOned X - Title Dme <br /> PLOT PLAN IDnaw to Scale)Soale_ •to 401 <br /> ' <br /> t. 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 /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN 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 /> :: . <br /> .. <br /> .. . <br /> _ M W. ... <br /> .. <br /> .. <br /> .. ... .... <br /> . <br /> ... ... <br /> Lo " <br /> : .. . .v <br /> - . <br /> v( <br /> . o'rE ..... 5 cr.L•�-<-�. <br /> JvM <br /> DEPARTMENT USE ONLY <br /> Application Accepted 0. n p" Det. �! Area✓. •`' <br /> Grout Inspection By Datev / Pump tnapowion By Date <br /> Destruction Inspection By Date <br /> Comments- �a � 4 -a'� <br /> ACCOUNTING ONLY: AlDA' FACR ✓-L)Z' <br /> PE CODES FEE INFO AMOUNT REMITTED HEC ICASH RECEIVED BY DATE PERMLTISERVICE REQUEST NUMBER INVOICE <br /> nQ�`' lsSl� 7S" D 51 <br />- I. <br />