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FOR OFFICE USE: APPLICATMN FOR WELL R PUMP PERMIT PERMIT NO. 7-z,- q <br /> (Complete- Anjriplicate) Date Issued: 3._I- -72_,. <br /> TH S PERMIT ERPIRES 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. 1562 AND RULES AND REGULATIONS THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> t7 JOB ADDRESS/LOCATION: f `wil1�r R.U. 3fYJ �_ © CENSUS TRACT: <br /> OWNER'S NAME- L (�� PHONE: J6 4-a217 <br /> ADDRESS: 2011 1 E Mae'p aq I'v CITY: aOI. C�q <br /> CONTRACTOR'S NAME: !� E v i ' LICENSE # 6MV/ PHONE: s769-3943 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /-7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER I / <br /> NEW' WELL: DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7o CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS: TYPE OF REPAIRS: /r og1.G �� �/✓1 �"rgG� �y��y <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: tr <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> f I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN S' <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 />{ <br /> SIGNED: CONTRACTOR: <br /> CONTRACTOR: <br /> 1 <br /> FOR DEPMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ' DATE: <br /> i ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR <br />