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<br /> FOR OFF=UiE. , ,T, k. {� :."APPLICATION . q.
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<br />? a e Non•Tnrtso rab",RarosabM,BusRsrtdabh! 4 PUMP&IA'ELL `' Y c ''
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<br /> ENVIRONMENTAL HEALTH PERMIT .. e ` �.
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<br /> ARPlleationbhe madetolhaBanJoa ulnLoceEHeatthDistriccfore a ePP
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<br /> reby q permlttoconstructandlorina;aillheworkhereindescrrbed Thla ficationl9`i .
<br /> nada In compllarlq with San JorlQuln County O trance No`1882 and the rules and regulatlana;of the Sen Jottquln Local Health DlslricL'� . ,r
<br /> =xact S.Ye AOdrep ' i L���l ��QaL� City/Town ---: j
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<br /> ;ontractors l+lame V.
<br /> License M ,�QD�/_3 Business Phone .A-. K_^/uaS y ,n
<br /> :ontractoYsAddress Emergency Phone ' ' 1 ,�11 f',
<br /> s c4kilicate of Workman's Compensation in mnce on Ftfe`.W1lh SJLHD7 Yes No 1 '
<br /> PYPE OF wTMIR (CHIPPK) r NEW'WEL DEEPEN D RECONDITION S DESTRUCTIOND �4
<br /> vELL CHLORINATiQN;� WELL ABANDONMENT 0 OTHER D PUMP INSTALLATION PUMP REPAIRG « t fih ., '
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<br /> IISTANCE TQ NEAREST Septic Tank, Sewer Lines .SD t it Privy '. r•i i
<br /> E Sewage,Dlsposal Field - CeaspoollSeepage Pit 011ier _ � t..
<br /> i r {,Property Line 'FClvatr bomestic Well PuhIIC Domestic Well
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<br /> INDUBTAIAL CA9LE TOOL -.Die of Well Excavation7. % rz
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<br /> 7 DOMESTlClPRiVATE' 4 OAILLED t': "Dla'of Well Caslnp `� 't` .
<br /> DOMLSTICIMBLIC `� DRIVEN Daupe of Casing �z r .� ,
<br /> 3 IRRIGATION ` ,GRAVEL PACK Depth of Grout Seal Q 11. - ; �.
<br /> "EATHQDICPRQTEGTION ROTARY . T;,pe-of Grout _-�'Pax��,t_t _ r " _Y�k�a.
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<br /> (s fYSICAL Surface Seal Installed By % ;.
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<br /> UMP IlW7ALRATIO1k Contractor ' -
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<br /> UMP iREpLAt HENT' .»� O State Work Done — ..-:: : .. _1 - {
<br /> UMP REP#IRS"' State Work Done •`)` { ' G�"
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<br /> ESTlIl1CTION-OF"WEiL. Weil Diemeter 1pproximat bBP ,
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<br /> I Aerebv certify that I have prepared this apptication and that the work will be done in accordance with San JoKwip Cqunty ,cam ' x-
<br /> - ordinances,state laws;and rules and ulations of the San.Joaquin.,Local Health District. ' J.t t ^ . y
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<br /> NpttirownerorltcarisedaglnCssipnaturecertllleatheiollarrl�:,"Icerti(ythatiniheperiprmanceottheworkforwhithihlspermit '� ,'' .
<br /> Is rsaued.I shat!not'employ any person�ln such manner as to become subject to wdrkman's compensation laws at Callfomla" i 3 e q-'s n
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<br /> 'Mumctorshtringorsutt-contractings4pixtur^cerdfiestMfollowing:'Icertifylha.inthepertormanceofthewDrktorwh,chthis i ' h
<br /> `permit is rssued f shall employ persons subject to workman's compensation taws at California" s !: �a
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<br /> 1L'I'tlliq sail far a'Grout 1 prior is grouP.ng artd a final Inspection .r, "� " ,r
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<br /> Appttcation%Acxepted B77 Y fI. - Dale(r"ri�►r/`j r�a
<br />', Addctionel Comments r �wr `: v r
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<br /> FM la fine:© ANNUALL7 - -1 �ER.Ur71T_ --'•LL P£H S17f _0 EACH -[3 January'a Recewad By Jtre.,iy 31 July 1`8,flecerMeA By July J. . : a' }�3„.'.-:
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<br /> 9A5 E%PLANATION - - AMpIJNT OLIE CHECKED � -
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<br /> YK�CANT—ItMRN ALL COPIES TO: ENMONMENTAL HEALTH PERNff,SERVICES ' teoi E.HA2ELTON AVE-P.O,040 NO � ETOCRTOK CA 216M^ '� �r
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