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FOR OFFICE USE: II APPLICATION FOR WELL OR;�PUMP PERMIT PERMIT N0, Z <br /> !� (Complete in Triplicate) Date Issued: <br /> '" !I THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED <br /> APPLICATION IS HEREBYMAD TO THE <br /> �. SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> f: <br /> JOB ADDRESS/LOCATION: 3197 Carpenter Rd,- .W. of 991 CENSUS TRACT:' <br /> OWNER'S .NAME: ;II; George Billups II. PHONE <br /> : 465 5124 <br /> ADDRESS: �h 250 May Ave. :II' CITY: oc on <br /> CONTRACTOR'S NAME: !��Jo �A. Thalhatner Coo LIC-ENSE �� PHONE: <br /> 471 1858 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL 14 PU$�LIC WATER WELL i - it L / / TEST WELL <br /> IRRIGATIION/LIVESTOCK/AGRICULTURAL_WATER WELL /_/ INDUSTRIAL WATER WELL <br /> CATHODI'CFPROTECTIONWEI,L / / GEOPHYSICAL WELL OTHER / <br /> NEW WELL: DISTANCE T01lINEAREST: .SEPTIC TANK 78 ftSEW R LINES 56 PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE! PIT 12(TOTHER <br /> REPAIRS: TYPE OF REPAIRS: T `Dt-i0w nd case six inmh Drell and install pressure system <br /> r <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: 1 <br /> ` a 4 <br /> 1 <br /> q _ <br /> L�I d <br /> I / <br /> PLOT PLAN:j SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT f HAVE PREPARED THIS APPL16ATION ,AND THAT THE WORK WILL BE DONE IN t y ' <br /> ACCORDANCE WITH THE PROVISIONS OF;THE LAWS OF THE STATE OF CALIFORNIA THE ORDINANCES.OF THE <br /> COUNTY OF SAN JOAQUIN, :XND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT,', <br /> SIGNED: Y,. E <br /> ,CONTRACTOR <br /> I <br /> i•1 1. t _ f.. _ � �I s <br /> "FOR D ARTMENT USE)16NLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. +i , ✓t>ZP�e�- - ----- DATE: 2131 <br /> ADDITIONAL'COMMENTS: III I � <br /> PHASE-II ' :; .- , ... <br /> •-� �-a-, �-PHASE-1-11 FINAL <br /> INSPECTION BY: I! DATE j� <br /> 7� INSPECTION BY: DATE Z. <br /> E H 1426 M� SAN JOA IN-LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />