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Appllcitions Will Be Processed When Submitted Properly Compleled Be Sure To Sign The Apntrcation
<br /> I FOR OFFICL JSE I .APPLICATION
<br /> (For Non-Tiansferabie Re+ocable Susper+dnble)
<br /> 1 ENVIRONMENTAL HEALTH PERMIT
<br /> I
<br /> (COMPLETE IN TRIPLICATE) WATER QUALITY
<br /> JIIC 010rI.5" *t ter,•1 tCt 101f S I J I u I L r I I It 7 L n IC ' ' 7 n^ 1.1 1 r r to h.,rf In r]_5CnhP,y This ippitcation is
<br />' `'' '1D.„tinct
<br /> <is 51 P ACC
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<br /> TYPEOFWCRK ICHECr, JE J 4r ELL C-- CrGn= ❑ -J CC'D -' ❑ UE= . TIONU C
<br />' WELL C''_ORINkTION ❑ WELL .13A,NDON' = T ❑ O``-'ER V C n , � �� . IL)N+ k', PU'AP PEPAIR❑
<br /> qE-L%CE LIJ-0
<br /> DISTANCE TO NEAREST Potic Tin., Cr 5� L r Pi rL 1
<br /> S_,.vTge D'SPOsii F eld :",suool S .235, 1”' --
<br /> prop"rt( L.nPI l -� P Ivd,C :3or Ic ,.n'I ) Pt b Ir Com,,, it, wl
<br /> ;MENDED USE TYPE OF WELL
<br /> © INCU-,T RIAL ❑ C-3,E TOOL D.I of t! E,. iV I „n
<br /> �'6CVES`IC PRIVATE Q vRILLEL7 DIi o' '. C i5ing
<br />' J DOt ESTIC PUel-IC ❑ CRFIE GiL q„ o1 Cnsrng
<br /> ❑ 'PPIG'-10O 4 ❑ GRAVE'_ PAC4 7,3-0,n C' Grout SL 1
<br /> ❑ CAT}-IrJDIC PROTECTION E�07.RY Trp. of Groi.
<br /> ❑ DtSPOS. L ❑ OTHER O i_r In'ormi i.)
<br /> ❑ GEOPHYSICAL Su f3c_ Seal In-,ti,1 ' 3+
<br /> PIJIAP INSTALLATION C^ ,c cr
<br /> T,a D' 0I.7 F,
<br /> PUTAP REPLACEMENT ❑ S t rz` '.rk D' I
<br />' PUMP REPAIR ❑ S i l 7 k Dr
<br /> /
<br /> DESTRUCTION OF WELL t II D.un -Z1411:11: Depth
<br /> De,c i^t it n II i iC P ocod Uro
<br /> T ' erL"( C� if, ha I ha+e prnpnrec' i s lo,l,L, ,I Ind Ih-i nP ,vork v I. 5^ L'Onn ,n Ici ormanee with S In Joaquin COunly _
<br /> ordw,ancas eta e liWs 'Ind rid s ind rtcurvien;,) '"e Sir Joaquin LOCII Hr311h 1715'rI-
<br /> Home owner or licensed agents signature c"13fies the following Ice I'y t1'i' r nP per'urrn s^C-nl Ile work for%%h.ch this permit
<br /> IS 1SSL1,C T 511,°i rot 'ii.)Ioy lov r I rs Irl I i SUE. i I i inr er is J I)et-orno ,uhf.L' Tv WO 4171 In 5 L,Umptnsalic 7 I-iws of California
<br />' Contractor s hiring or sub contracting signature ce lilies the following I C-r 0y rhl n'h I•,norma 1co of'h,+ WK forvrhlLlI tMIS
<br /> ,)er no s ssu:!, I shill employ o'rSUPs.,,.71r c o �rorarra.i s eornnen53'i3n I-iws of C't'Ilorrnli
<br /> I call for
<br /> /a GJDuI(,nspecuon prior to grouting and a final inspection
<br /> Signed XML/ J /�.i -- Title _�/r•�r lei.*/� Date
<br /> / 'DI I% P of Pr Irl on Ri verSE SrOc}/
<br />' FOR DEPARTMENT USE ONLY
<br /> PHASE f [�� ] , ,� 1 (O
<br />' Aopl.cition ACLepted B, '` 1 _'`k1ft�i �ecj
<br /> 4y ` C1�te 5 � `� X1.1Ac'dillnnii C"mmentSeh e 0 rro'r tnspertton 7 7 rct. f ! hM Final Inspection �f
<br /> Insprctron By//�y� `L J Dit /n •- , Y i 1 t$� r it SPe LI 3y l�•'I h,`'s
<br /> Fee Is Due ❑ ^ ti ,. ❑ ,« , - r r rI .�, ❑ I. \ C �.Ii,i.v ' w r n. .I ❑ j 1, I W n 1 . nY
<br /> +5`oUV DUE CtHIEC1KED
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<br /> APPLICANT-RETURN ALL COPIES To ENVIRONMENTAL HFAL rH PFR111-SLnvICES 1601 E HASLLTON AVE PO Boi 7009 STOC%TON CA 95:01
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