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<br /> Apphcatlons Will Be Proressrd When "-ibcrnlyd Piuperly C.omplclyd Be 5urr iV Sign The App J
<br /> FOR OFF:SE USE. APPLICATION +�
<br /> (For Non-Tianslefable. '-vacablr.Suspendable) r
<br /> �' -- — 1 ENVIRONMENTAL HEAL-1i PERMIT /
<br /> Uj
<br /> (COMPO-TE IN TRIPLICATE) WATER QUALITY
<br /> Appl,cdt-un,,hereby mdae lu the ben J.,uqu�'I U�ca111ealth District 1"1 d pnrtr„t to t.unstruct and ur n. 'dl t ��•wurx herein descnb�d This dpplledLun >
<br /> rrimu In(.orn(,l,dnce woh L:dn Joaquin County WomAnce No 18t)-',a ml the rules and r^.gulations of lrte c,:n Jrodquin Local Health District.
<br /> Exact Site Aadresss ?4,/.0 111!' /-tir7 -e r— ```` City Town
<br /> w114f'.
<br /> On /
<br /> er s Name 1"f t ' e A r•r 1i/S1 14.4 /1•t�o .✓!� Phunu�?C J�
<br /> AodresS !/c C /T1.�� d/•� City I/ C�
<br /> �� n c LICense BusmesS Phone
<br /> Cur,tr.{rtorsName/�i��r../.�e•.� <`i ��c �� G/YK.' " ,�/tr�•l� /i./ 'I✓Ir
<br /> C.,rt,dcturs Aaarc•ssC
<br /> 2 CC ti• JfLe'JC4 �''/j c'L f Ci Ernergency Phuni <
<br /> I.- :W1,,i1LCtc-of Workman s G,: -pu-ndtrun Insurdr.ce un Fitt, 1,V,th SJLHD' Yes No X�
<br /> TYPE OF WORK -CHECK) NE>.J WELT;. DEEPEN Cl RECONDITION 1-1 DESTRUCTIOppN��❑
<br /> VvtL L CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION pr PUMP REPAIR❑
<br /> REFLACEtlEN1 U
<br /> DISTANCE TO NEAREST Septic Tank //e- 4,4- Sewer Lines/, Y' oe,- Pit Privy I/e.tl
<br /> ,,•)wage Di:,t,,,.,ii F - ;IV4•i✓ .i. cva,,,Uuoi See ac c Pit r '' ! /
<br /> p J /�sC / e— AOlhe, �,.c,�c Id—
<br /> III.
<br /> 3
<br /> III.,;T-rIj L�n.1?f �'I., . ,r,. D.,,i,,tA-C LV r'li/��/'I�./1 PUt)I-C Dow.:,tic Weii It-lbeV !—
<br /> INTENDED USE TYPL- OF WELL
<br /> ❑ iNDUsTRIAc CABLE TOOL D a of Well Excavat3wi
<br /> >ELDOMESTIC PRIVATE D DRILLED Dia of Weil Casing
<br /> ❑ DOMESTiC PUBLIC ❑ CRIVEN Gauge of Casing j cL
<br /> ❑ IRRIGAT ION ❑ GRAVEL rG
<br /> An Orptn of Grout Se,rI v3� ��—
<br /> ❑ ❑ FIO I AfiY Type of Grout �<<n r,
<br /> ClDI>,w.) ::, D �rtFFa ,tnr• Int,„,n.ih•"� �
<br /> ❑ C i1N.1 �` Surface Seel InSl.olea iiy D/'! �0 1--
<br /> PUt- - rY';TALLATION: C-:.��.,..t_.i /�%t Qci!•c'c!.< lL�!( Orr /��Nj f �u.../J S!•'r:. c_ �)
<br /> PUMP REPL AGEMENT. ❑ `Lfta i;
<br /> PUMP REPAIR ] �f
<br /> DESTRUCTION OF WELL Al'F,r ,xur,at,:Depth ,
<br /> . �•' , •, f '. i' ..�,w w,l! 6e done n. .i(curd mLl!with
<br /> :,un Juaquur CuUnly
<br /> L if; Health D:>t •,t
<br /> Home owner or licensed agents signdlurr certifies the lodow.r g , u,..•;ierir)rn,anr:euf the Aork.fur wrnch Ih"1.-•rnnf
<br /> 11.. ,, , ., ti. r r.,.r.s cumpt-115d',gin taws ul Cd4forinit
<br /> Conlroclor s hung nt sub-conlraChng s,gndlure certifies IT, I:JIIowinI
<br /> 3 � r t.nr•,an,, -'--. .v h tn,�
<br /> 1101 /J tall for
<br /> /a Grout In ction prior to groaun
<br /> ng and a twal inspectio
<br /> Signed X
<br /> Tille �! C'Z �u-` Date'
<br /> ✓';i•: 01� ;I••.r r-••_ ..r7�•.
<br /> / FOR DEPARTMENT USE ONLY —
<br /> PHASE I
<br /> Phes*If Gut Inup cctiootV
<br /> ��roG�✓y `I ` /� �! Phese III flrWl Inspection
<br /> Fee Is Dur ;
<br /> I
<br /> ___- APPLICANT tie tU..y c„ .. 1•.. V,r. ,
<br />
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