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FOR OFFICE USE: APPLI ION FOR WELL OR PUMP PERMIT PERMIT N0. L•19 <br /> (Complete in Triplicate) Date Issued: <br /> S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED may <br /> J ! 25` �✓ rFr6-Kw,q Y,, .. �� 6d f- �cr rn �-6 O <br /> APPLICATION IS HEREBY MADE TO THErSAN 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: .Cam ')22, 'Upper Dories Tract' <br /> CENSUS TRACT: <br /> OWNER'S NAME: Ensher, Alexander & Barsoom — PHONE: <br /> ADDRESS: P.O.-Box 27 - CITY: Fro It <br /> CONT'RACTOR'S NAME: ­ J. A. halhamer Co• LICENSE it PHONE: <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL / / PUBLIC WATER WELL A*/ 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 150f't. <br /> SEWER LINES 150ft•PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER '— <br /> REPAIRS. <br /> THER REPAIRS: TYPE OF REPAIRS: Brill and case 211F inch plastic pipe well for labor tempo C <br /> kk <br /> I <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: r <br /> PLOT PLAN.:-..SHOW ON REVERSE SIDE <br /> ti.. <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORIDANCE-WITH THE-PROVISIONS OF-THE'LAWS OF THE -STATE OF dALIFORNIA, THE ORDINANCES OF THE + <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. - <br /> SIGNED: <br /> ISTRICT. -SIGNED: :: <br /> CONTRACTORi <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Y Za- <br /> v <br /> APPLICATION ACCEPTED BY:+ ;1~ <br /> �- -".. � DATE: � L , <br /> ADDITIONAL COMMENTS: , <br /> SE II k.. PHASE III/FINALOT <br /> VVi <br /> INSPECTION BY: DATE INSPECTION BY: GcJ DATE <br /> E H 1426- - SAN JOA UIN LOCAL HEALTH DISTRICT 1/72' 1M <br /> 7ISTRIBUTION: WHITEw-HEALTH DISTRICT YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />