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Date <br />Ares C--) Dete <br />Data <br />ACCOUNTING ONLY: AID* FAC# <br />DATE PERMIT/SERVICE REQUEST NUMBEFI <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />Pr MONITORING WELL # <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL # <br />OTHER <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />SOIL BORING <br />0 <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME 43e.:1- 14-,-) 6 E <br />GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DRIU_ER: 0Y.. ONO S <br />S <br />qMOMTORING <br />APPROX. DEPTH / FeE-; <br />A <br />0 <br />0 2.4 <br />DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEE1.7 <br />DEPTH OF GROUT SEAL <br />AIR ROTARY AUGER V"- CABLE OTHER <br />LOCKING CHESTER BOX/STOVE PIPE <br />INTENDED USE <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />AGRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION " '70 DIA. OF WELL CASING <br />SPECIFICATION <br />42 <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: '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-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE 4.1PPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (200) 4014422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X 6a,?0,1 <br />PLOT PLAN (Draw to Scale) Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FTcp <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />t(14(1r° Date <br />AMOUNT REMITTED <br />I 89 <br />CHECK/MASH <br />52s 21-1 -?fr _5(WDD`5513 <br />PE CODES FEE INFO RECEIVED BY <br />.35ot MIAA- <br />INVOICE <br />Pump Impaction By <br />Data <br />' to