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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PEI;41T PERMIT NO. 7Z�Z'5 3 <br /> (Complete in Triplicate) Date Issued: gni <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE 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. s' <br /> j <br /> JOB ADDRESS/LOCATION.;!'" 3716 .Clark Drive CENSUS TRACT: a <br /> OWNER'S NAME: James to ey PHONE: <br /> 462 4445� <br /> ADDRESS: 3716 Clark Drive CITY: Stockton <br /> CONTRACTOR'S DAME: J. A: Thalhamer Co. -- LICENSE # 272 3Q3 PHONE: _77 1858 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL /_/ <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 86 ft SEWER LINES 95 fiRIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> REPAIRS: TYPE OF REPAIRS, Drill and case new six inch well, to replace old contaminated <br /> well. From old cell to new well is 44 ft. To install new pressure system to <br /> present tank. Disconnect old pump from new -system. <br /> ABANDONMENT/DESTRUCTION: METHOD-TO-BE USED-. Old well to be used for irrigation. <br /> � i <br /> t <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH-THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN/`JOAQUIN, �AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: L' jjL CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY:(�av,��-A-jsz <br /> DATE: /! <br /> ADDITIONAL COMMENTS: r <br /> /.,V <br /> I <br /> PHASE II PHASE III/FINAL .' <br /> INSPECTION BY: if P. DATE INSPECTION BY• DATE _ 6 -2,7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />