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Applications Will Be Prncpssed When Submitted Properly ComPletoll 8� S� ;f yqv 4pe tcaflOn. j; <br /> FOR C-FFICE USE APPLICAT 10 <br /> 4.� J, <br /> 'For Non-Tran-ifo-rable, nevoci bil J <br /> ENVIRONMENTAL H <br /> EAI-4;4EAM� I ump \*/ELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 71- -,t!,-I This ar0-7.4" <br /> Lor-Al Health D-StIr <br /> Exact Site Address <br /> 0 Afnt-Ir--Namp 6,+a <br /> AdIress .1 y P p 9 Na Gv* _ <br /> kn'v Is tv /Z -I C!o j <br /> Contractors Name LIcF`mSF`it <br /> Contractors Address Emprqpnr.v Ph ane <br /> 1,,Cert hcat9 rt Workman s Cornperisat-on lnsuri,csl )n File%It' ';JLHD) Yea I--- fVc <br /> - <br /> TYPE OF WORK (CHECK) NEW WELL 13 DEEPEN Ll REC0N0I-i'-.--0 rF <br /> ViELL CHLORINA71ON 0 WELL APANDONMENT 13 0 rHER 13 1 N '-'•LLATiONW PUMP REPA IQ E3 <br /> �F-LACEMENTC <br /> DISTANCE TO NEAREST Septic Tank Soo-AP,L—IS Pit Privy <br /> Sewage Disposal Firoki Cesspool Seepage Pit Olh.a <br /> ,a <br /> Property Limp Private Well PL-bl,c DomPS1,C Weill <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL C3 CABI E TOOL D-n of Wfoil Excavation <br /> 13 DOMESTIC PRIVATE 0 DRILLED D"t �#Woll Casing <br /> 11 DOMESTIC PUBLIC C3 [)RIVEN G;Iuqp of Casing <br /> -RAVEL PACK -1 of Grout Somal C3 IRRIGATION Dept <br /> C3 CATHODIC PPnTECTION ❑ POTARY Type of Grout <br /> y. <br /> C OISPOSAL r-)THER Otmp,1-,formMinn <br /> ❑ GEOPHYSICAL sts'!1coo,Sf%Al Installp(i By <br /> PUMP INSTALLATION cc-nlr lcto, <br /> Typo o- Pump <br /> rimp REPLACEMENT C Slate VInrk Dor, <br /> PUMP REPAIR- 13 State Wnrk Dome 1Sn.aM oma.-1 14.1, /-0 - /L"-Iv-ll.+u• <br /> DESTRUCTION OF WELL: Well clampter <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this apol,cation and tm.j! the work wal be]Onix if, accri-lance With Sam Joa,-,-.i ri C-0vntv <br /> ordinance,; !%fate laws.and rules and -qt,latfons ol trip';an Joaqu-m Local Health Dilttr,r! <br /> Horne owner or licensed agent's signature certifies the following: I certify!hit in the performance of thp work fro,wo,-(7 h'ht'; <br /> IS ISsLio`d I %tall not employ ani person in silr.h manner a5!)bern-e subject to Workman 3 COMP(InSall0m lay.'01 CA1001MIR <br /> Contractor s hiring or sub-co4 dracting signature certifies the following: Icelill'ithat,"the r '0conAmce0f to for wh lch thl" <br /> permit ,, I sma I employ persons Subject to woro,inam 5 comPOnelatin't laws Of Cal"-nia' <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X eA.,4, z �bAv-qw Date: <br /> (Draw Plot Plan on Rev-wse Sidei <br /> FOR Dr4PARTMENT USE ONLY <br /> PHASE I � / / <br /> Application Accepted By ��/J3�9 <br /> t <br /> Ar, !-tional Comments Ift-fise 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date n o" <br /> Fee :s Due- 13 A-I ❑ I'Fr !N- n-pro ti,-s 0 FA G I" i P,-- rt Fly J Jr,t"J,, <br /> PASE EXOtANAT,ON PILLING F S AMOIJN'DUE <br /> nATE REMITTED AMOUNT <br /> FEE J/4/ S— <br /> LESS <br /> PRORATION <br /> VIL LI <br /> PENAL'y <br /> JTmEA <br /> L4 �I- <br /> 7ci— ll I/ -7 <br /> A.. r,R—q)!NPi,—t N,, Istum.co, At@ Mad,ri 0o1........1 <br />