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' - Appllcdtlons Will Be Prncessv(I When Submitted Properly Cornpleiad Be Sure To Sign The Apollcatlon
<br /> FOR OFFICC JSE APPLECATiON
<br /> (For Nen Tr-ansfer2ble Rev�cable Suspendable)
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> 1COMPI ETE IN TRIPLICATE) WATER QUALITY
<br /> ,11C ltlOn 15- rl" n ldr IOIn S;' J I i L , 1 Yi rt In d,)5cr.hPd This ippNCatlon is
<br /> n, I Corn^I to, ..Ili b in 7111 1 , ,` , ' 1 � cyn
<br /> a .n Loc I P 11 "i DISIRC[
<br /> J t
<br /> Cztc 51[eAndress G, C/�L_ C/ 1/�� f' r �t G 1 T, �a ��l`r
<br /> C vncr, ^J lm,, Ill✓_ L t �' 1 Ll�
<br /> Address _�[.F� ..._. r , C
<br /> C''7ntr 9[ Cry N I^_ �✓, t � 1 f ��/_f iri if/i� .yl, �� 1j '�G IL 'i/ + I 1 tiS nr,Gr� lf���� L� � 4 �
<br /> COn'ric U 5 AOI r"5, l�L' Cr JC ! y r/fG '1 F"er
<br /> 15 Cr_r .`ICJ a of 'C k 11n 5 CO*yE.„^at L^ r Si 1,CI On =I ^ SJ, 10" f 5 r-r Nv �
<br /> TYPE OF WORK CHECK 114F lL4k!LEl' DEEPEN ❑ n=CGVC' -1 r DES'd JCTION❑
<br /> WELL %iELL .13A-IDON' EP" ❑ 0-w4ER ❑ r n JiT 1L_,TION PUfvS?PEPAIR❑ '�
<br /> REPLACE,'FN-0
<br /> DISTANCE 'O NEAREST r rptic Tinti L � �- � r of pn,r
<br /> S'vvi n D s Dsll F,elij Cess or)t i P, c /
<br /> 9 P G e w 7` ��1 QI'1tr
<br /> PrOD-rtL,ni, !/ I P ivatC
<br /> / ! - :mor*., tic . ell 1-5— ?l,b IC F✓`7mr lnPi
<br /> INrENDEl7 USE TYPE OF WELL
<br /> ❑ INDUSTRI.L ❑ C,,S,E TOOL D.t cl ,II E, lvi .-Il
<br /> ❑iJQ'.ES-IC PRI LATE © DRfLLED DIi o'%Jl 11 C Ising
<br /> J DO[ ESTIC PU3LiC ❑ DRIVE., Giugr of Cisrng
<br />' ❑ IRRIG.,TION ❑ GRAVEL PAC;- Ceoth of Grout Sell
<br /> ❑ CATHODIC PROTECTION ❑1 OTHFi f T,pt_ of Grout Z:�-' tom. e 7 r�
<br /> ❑ DISPOSHL ❑ OTHEn O i jr Ir'ormi Ian f
<br /> ❑ GEOPHYSIC- Su'fac_ Sial In tt.' 3v
<br /> P'JPAP INSTALLATION Col Eric cr _
<br /> rrp„ O ❑ t H P _��
<br /> PUMP REPLACEMENT ❑ 5 1 1, w Dan
<br /> PUMP REPAIR ❑ S lr DoFI !r ♦r/ //�� J i
<br /> DESTRUCTION OF WELL I D.it i L L L /�/ .'f /r/ r T 1 -it,Dep �J [
<br /> D',c P^t I it rlil ind Pfoceduro
<br /> I �u Lam! Ce t1' ha I hive pri,pired 1.S ip;.LL 1 Or ind that ire work At I be done In act nrdarca write S in Joaquin County
<br /> O rOlnirC"5 Sate li%j5 and rt I s im, rz[rUI th UnS W ne Sir Joaquin Locit Health OPS ri-
<br /> Home owner or licensed agent s signature certifies tha following I cer Ply to it m P`W perfof rn,inr_of the wort,for%%hich[his prrmil
<br /> a Issuad ' seri°I rot eln,�lOy my at rsnn P, s,c 1 I ,]rarer is SJ`}ecor-1n subfT'r tO tivor4rn u1 s c.omp�nsituln Ings of Callforn¢a �
<br /> Contractor s hiring or sub conlracling signature ce lilies the Iollowing I C�r,dy i i n he performance of the woPK lorwhu,h this
<br /> 1 per nil,s ssueu I snill employ persons �L.`11r C o ,+orKrran s Compensai+on latirs Of Ciiitorn i i
<br /> I tail for a Gri?ut_,nspectlon prior to groulPng and a final inspection
<br /> / / Gra
<br /> Signed x -'�f /' ��/�.� '�_.__-- Title !'i-��f�f �f/�iryLri,�/' Date /_�
<br /> / 1 rDr rat 'til PI in an Rcveree Siae}/
<br />' FOR DEPARTMENT USE ONLY
<br /> PHAsi I
<br /> AD;il.cation Accepted B, 1 QV""
<br /> 1 Additionil CLmment5 _ ^�Z••` L � t
<br /> ro� r lnspelion
<br /> .�h�edt,G /^- 4Gj
<br /> + h e r iteFinat Inspection
<br /> IlnspLLlion Sy Ditr rD
<br /> y' v
<br /> Fee Is Due Cl -,c-l 1 - 0 I i is I r o [i . J/ , n J nj�►vr ' Y . H. i 1 I Q h I. 1 L 4 r 1 Ely FEh.IIT
<br /> al yti� ti �� t1I_ 1 n[. I T+vC` n1fOUV DUE CHECKED
<br /> r ❑A rF it li IF1 nh10UV1
<br /> �ilA If]Y
<br /> FNA
<br /> r`FVAL"�
<br />' OTriF 11
<br /> U "Eq
<br /> I v .1r 7. s =. N 1 I k,u ar,L�D Ie Ata Jeq D,I.vv,e
<br /> Ili-- APPLICANT-NFTURFI ALL COPIES To ENVIRONMENTAL HFAL rH PFR/U'Sf RVICES 1601 E HAZELTON AYE PO El—1009 STOCMTON CA 95:01
<br /> 41
<br /> 15
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