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<br /> Applications Will Be Prnces.ed When Submslled Prope,fy Completed Be Su-e Tc Sign The At pl,clbon
<br /> FOR E USE APPLICATION
<br /> (For Non Trans,erable Revocable Suspendable) , N
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<br /> � ENVIRONMENTAL HEALTH PERMIT l
<br /> (COMPLETE IN TRIPLICATE, WATEP QUALITY r
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<br /> TYPE 6F WORK t I,f Cw r NE4 LrEll DEL E ! C1q['C` DnU
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<br /> I It 0171 T1,) ❑ WELL .HANDL,) 1r Lr TX OTS+E R ❑ PITr7F1
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<br /> 111 T tNf F 10 NF%REST 5 ,Ti- TV* ��� $r >,-r Lim s r P
<br /> S w tqe DIsorvil Field LI ssonc' r t•
<br /> 0,,)perly Lint Pr+,ll Dom 2s IC 4t',II Ft r). Cnn t stir 41 v
<br /> INTFNDED USE TYPE OF 4%ELL
<br /> l❑ Ir4ittJ,TRIA[ �51CAPLE TOO_ DI, of J,11 E t iv I lurl r'
<br /> KPON'C 0 rC; PRIVATF ❑ DRILLED rill of'.'loll C I Irlr)
<br /> ❑ i)CIMILbTIC PUBLIC ❑ DRIVEN G,cr,r-of
<br /> ❑ IHFM1 ATION ❑ uti r
<br /> G1TavEt PACK Dr F)u r,r rr ,I ,r ,I �j i
<br /> —❑❑ CATHODIC P13OTF CTION 0 ROTARY Tyrie of r;r,cI -?—
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<br /> Dl',F'OS.,s_ ❑ OTHER Otht r Inlorn,, ,,r, * ]
<br /> ❑ GEOPHYSICAL SL-j ire .r 11 Irl-I lli 1
<br /> PUMP INSTALLATION Contractor Oct Zf/v
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<br /> Type of Pump 5
<br /> MP REPLACEMENT ❑ Ss I e Work Dons
<br /> UMP REPAIR ❑ Mate Worlt Dnnn
<br /> DESTRUCTION OF WELL t L11 Dlamp or
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<br /> Desc the f,' lerlll lnInc:�r(r� dl,re 1,
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<br /> Cnrtrl l thin I h IOP pre,artd Ir^e lhn J11LI i,) i w Plit ill+ r t)r. , 11 n i,, , r 1rh', Ir } r,r, , t-, ,tl
<br /> ordln inLLS b'lle 11VIS and ruleS and regal ILonS pl t^ 5,,m Jol=t in L x 11 V11 l R, r
<br /> Homeowner or licensed agents slgnatLre certifies the'ollowing I c+r .t j Ir )r r h1 I r r ,, [ + t <. rr r h ',m )+r-7 1I
<br /> 1S °i%lied 1 sh 111 not em JIOO any person 1n SIIC', minn,t 1^ it, b,c n,I+tiunrl t i r w u, n I, r,, I e II ,n 1 nr A C 01furnl I
<br /> Contractor,hiring ur.ub eortraet ng signature cc 116es the following a i t, I, I it w rk r ,r ,r+n n It 1s
<br /> U,'rm t IS 155ued I Shelli employ persons- IhICCt to w•,rkn in ti, ,mel+,",t1
<br /> I %'r 11 all for Grot,t Inspection prior In grouting and a final inspection J
<br /> Signed Xtyra/�dd2/Z(yQ 97-�
<br /> Title 6e_-) �O le7lt e!e Dlt�
<br /> DrIW Pli I r 11n rin Rr ,tr
<br /> FOR DEPARTMEN 1 USE Or LY ry
<br /> ' PHASE I N _
<br /> Application ACCepte, d, ����� In �� •�- t� t71t1 ^��' ~"� r
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<br /> Phase Ir Grot.t Inspc tion Ph nE Ill Fyill Insptchan
<br /> ' inSIE)CLbOn By Dlir ' ' Ir 1, r, Il' L.
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<br /> Fee is Due ❑ _ LY Cl 'E" ❑
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<br /> APPLYANT R,TUnN Alt.C')PSeS TO ENVIRONMFNTAL HE k, H PEnrA T SCRV CES ,S9 E rtAltt TL1+A,E PO Roe 24Uw STOCKr',N CA 45291
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