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poi^dam/9 <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. '72 - S -11 <br /> i <br /> (Complete in Triplicate) Date Issued: yp . Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> . # <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 /> DKD l7P- vJQr-�PS OnweH 7/l/Pt . Nv. 00 DC iAe 16.5 A20. <br /> JOB ADDRESS/LOCATION: P1:-LT1E2 -RO p- D.Evjej._z5CENSUS TRACT: <br /> OWNER'S NAME: C�pLUz►.rtlG f-y42�+S _ ff,�{ ;PHONE: "3 G 8 G SL <br /> ADDRESS: 13222 Al C.cIn2�yvr . <br /> CITY: ,+,,d�j <br /> CONTRACTOR'S NAME: l- PZMMO-5 LICENSE # PHONE: _moi 4,9 5o Y <br /> INTENDED USE: INDIVIDUAL'.DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL _INDUSTRIAL WATER WE / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELT-7 LL/ OTHER <br /> t" <br /> I <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOZ SEEPAGE{PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: =4 -a <br /> ' <br /> � I <br /> 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED:.- <br /> 7 � I <br /> r <br /> i <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 S 'JOAQUIN AND -THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> _f <br /> SIGNED: xg CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> Irk <br /> PHASE II s PHA6E III FINAL <br /> b ' <br /> INSPECTION BY: DATE <br /> ,INSPECTION �7wDATE �� <br /> E H 1426SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />