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74-,�,� <br />FOR OFFICE USE:APPLICATION FOR {WELL OR PUMP PERMIT PERMIT N0. <br />(Complete -in Triplicate) Date Issued: 3 -72,_T IS 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. <br />JOB ADDRESS/LOCATION: ` 113b3'N.�'.Davis Rd. _ CENSUS TRACT: <br />OWNER'S NAME: Tony Martin-- PHONE <br />ADDRESS: CITY: <br />CONTRACTOR'S NAME: Joe Machado ow LICENSE #2)5977 PHONE: <br />MW I <br />INTENDED USE: INDIVIDUAL.DOMES"TIC WATER WELL /moi PUBLIC WATER WELL / / TEST WELL /-7._ <br />IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br />CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br />NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 140 f%tS,EWER LINES 100 PIT PRIVY <br />SEWAGE DISPOSAL FIELD -6,5 -fiMSSPOOL SEEPAGE PIT OTHER <br />F <br />REPAIRS: TYPE OF REPAIRS: Fill and case six inch well and install pressure <br />system. <br />Well: to be drilled�bY J. A*'Thalhamer Co.' <br />Lie. no.272303 � <br />ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br />J <br />t i <br />PLOT PLAN: SHOW ON REVERSE SIDE J <br />,t <br />[ f <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 S 'JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br />t - <br />SIGNED : f 1 CONTRACTOR: <br />E. <br />FOR DEPARTMENT USE ONLY <br />PHASE I _ <br />{ <br />APPLICATION ACCEPTED BY:( <br />ADDITIONAL COMMENTS:-.-..---. <br />DATE: <br />PHASE II PHASE III FINAL <br />INSPECTION BY: b6t/� "DATE INSPECTION BV>Re DATE ."� -71- <br />E H 1426 1 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br />DISTRIBUTION: WHITE -HEALTH DISTRICT YELLOW -PROPERTY OWNER - PINK -CONTRACTOR <br />..j <br />