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FOR OFFICE USE: APPLICATION FOR WELL 'OR PUMP PERMIT PERMIT NO. 77 Z,- Z F <br /> (Complete in Triplicate) Date Issued: --1 : � i <br /> E <br /> HIS 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 /> THEWORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO.111862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB! ADDRESS/LOCATION: Fj RST S7- X -OF FL &Mde.-HL 50W0 ENSUS TRACT: <br /> OWNER'S NAME: b Al CIA PHONE: 7:- <br /> ADDRESS: Q -_q_SSSS F=. _ --:'�.1,S i i• _ CITY: AF-5G i9 4 oAf i <br /> CONTRACTOR'S NAME: , T, L,q ,e S�N �u/�J p5�T, LICENSE 1� y (a PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER LL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_INDULL <br /> STRIAL WATER WE <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS. 2&�_—.Jq /S !-�. _ id' s J �/ '_ „, i✓!: _ .. �N <br /> X/5ThV LL St C 7 R /2E <br /> Ofy <br /> I! <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> I , <br /> E LL_S - EFE0161al I 1\4 S CL P,u t - <br /> I� <br /> PLOT PLAN: SHOW ON REVERSE SIDE ' <br /> I� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH T ROVISI0N5 OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OFSAN JO U THE LE5 REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNID: CONTRACTOR: 91 <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> li <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> �E <br /> I! <br /> I� PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: c DATE , <br /> E H;1426 SAN JOAQUIN _LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />