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<br /> FOR OFFICE USE, APPLICATION I
<br /> (For Non•Trllrsferable,Revocable.Suspmddbie) f
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> (COMPLETE IN TRIPLICATi) / 11TE QUALITY
<br /> Ap li )
<br /> [' cation,s h�+nhy rade tOlhn fan Jo,9q li*,170.11 eiP!111h I-):cr,r t 1,�r l Pr•rnit")(:rnti!r r.S f!rul l,'.ir dv ir. hnrnn! dnSpibrd This ll'i•I+Callan is
<br /> 'n.+•1^in r;nmr'LA•t(..hi!h^,1n }n.1r; .int Gr i_ ., ,,n,rj�rt. t.�� +,. Ito .-rrrf •t , rt, , ,, rr . .. ..I„ }l.r�lru l•x/"*$10"111t �5tnP'
<br /> Ownnr 5 Name �� 1e � �� QTc: r1 �. � r � t°!, .pin 1 1 — ,S �
<br /> Address G��_S ryry��n-T�•n C� �,tY -STe,c,-k re, r.
<br /> Contractor ^IamP ��� i — -SC'• .,y ��*1r� l-r4+'r r• r ]r2'L�y I tr inr• i'ts inn 3�' -�� ? �
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<br /> CJn[ractur s Adcress �3(r. `-�(� is r Ll+ ] r -3 Qr n`;v 4'h >n:•
<br /> Is Certificate o1 WorSmar's Comppnsal on lrSmrarce on File With SJUKDt +" No
<br /> TYPE OF WORK 1CHECKI NEW WELLO— DEEPEN ❑ RECON10"IUN0 DES IRL'L.IION❑ —�
<br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ Pi ',IALLAt+UNA^' PUMP REPAIRO
<br /> REPLACEIMFNT Cl
<br /> DISTANCE TO NEAREST SnpliC Tank S^Wer Li"I'S Pit Privy
<br /> SewapA Disposal Fietd Cesspool Seepag"1711 Ot"er ---
<br /> Property Lings G� Private Dorr+r-stle Well _ Public Domestic Wlll
<br /> INTMDEO USETYPE OF WELL
<br /> ❑ INDUSTRIAL h9 CAE3LE TOOL Dia.of Well Excavation
<br /> 1DOMES11CIPRIVATF © DRILLED 018.cil Weil Gfift _.-
<br /> ❑ DOMESTIC PURt 11 © ;,nIVrP4 nat.c)"of Casing J:=
<br /> ❑ IRRIGAIipN ❑ CI1AVLa_ PA(..K Depth ul Giaut svcll t
<br /> ❑ CATF+OpIC PPOTFCTiON ❑ ROTARY type+of Grout ?—.a
<br /> ❑ nt^un5�t ❑ r)".f rt Other Intorrnntion
<br /> ❑ Lel Jl'IaY',I, AL Sanas/Sfral In,talk"d fav
<br /> PUMP INSTALLATION: e;,.,it i. !
<br /> Tyftn Of Pump H P 4 �/
<br /> PUMP REPLACEMENT: ❑ State Work Donn•
<br /> PUMP REPAIR: ❑ S1atn Work Do.-
<br /> DESTRUCTION OF WELL: r Well Dofnetrr Atipr t. mllr,Dr'n[li
<br /> Gn'Iribr Mllrriai arta PFmek1llrr+
<br /> 1 Itrrr+;ly ;,"'Wy trill I ^a,r pfr carpe• this rIppl-ration and that lhd work w,l1 he done in nr.r.nrdanrr w+th",in•toarf(jin County
<br /> ni{ltnrint r.1 '.i.iU+Iswa r.,i ,'t ariri rrgniati-s1•)t the Stn IOAClt'ii Lncnl Health Oi+tttc t
<br /> Homt owner or licensed agent-s slgnAlure crrlilire tho following. I cert+ly th,al in Ir,nf,r+k,rm,lra n of thew rk+nr w+'ir.h;ht;ls,+rmlt A
<br /> r5,clued, I Sial❑nni r.t„rany ,n y!,riA,trt of�ui.h —nnnnt n5 to hrl:,rmr,+uhirct Ir,woil,m,ul t 4C mpnn sAhP 1 .iw:Of Clllfr)r oil
<br /> Can tractor's hiring or sub-conirattlng signalurr eartitles tho following: I(-rtilly it',Fit m Ih^per Ltr•nnncr of tt,r Werk for wtjt('IN [his
<br /> , , art m,t rs ri5ur•d 15n,1`I r-mr,i .y r,^,t, ni 5lihl41rl !.t wnrl,r-,ln s(nfnftrna,ltipn taWS 01 CAfr OMil
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<br /> I will c It for a Grout Inslfrcttor+prior fo.grouting and a I,nat inspoellon. i
<br /> r ems.` [- ••- A n Title- l + V ,'�
<br /> signori X J et ! 1 `4'l . !�. 1�1b�t� L+,�4
<br /> loraw Piro r• ,.t-11 it"rr'Cr 5+(11') +
<br /> FOR DEPi.IgTiAtIlIT U7IF_IU14LY
<br /> PHASE I \1 )� 1��!&4 [
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<br /> . P4ati It Grout+ispecflonf t Pf1aaaill Final Inspeclion�
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<br /> Aw►e{CAMS Rr1VAN Ali.CDMfb Ta {0(y rR Or(YfNT AI.HCAL•M MIIY+f ff RYIUi IMt f NAI[lrar AVS,►O /w>t M0� fITnCA70Y CA Mir
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