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FOR`OFFICE USE APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. ,,;E <br /> -- (Complete in Triplicate) Date Issued: x_ 7_sz-7.Z <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 /> 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 HSALTA DISTRICT. <br /> JOB ADDRESS/LOCATION: N"br-� CENSUS TRACT: <br /> OWNER'S NAME: �' e-r 11MV PHONE: <br /> ADDRESS e� ra' CITY: d'__4.c111kA1 n <br /> CONTRACTOR'S NAME: -4 U1 LICENSE /CL�7ds'-PHONE: 44 61- 7L 746 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL LW PUBLIC WATER WELL L/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCR/AGRICULTURAL WATER WELL L-7 INDUSTRIAL WATER WELL/ <br /> CATHODIC PROTECTION WELL L/ GEOPHYSICAL WELL L`T 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: Ty> n ik /4 e- Q <br /> 0 <br /> ABANDONMENT/DESTRUCTION: METHOD„ TO BE USED <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 J QUI PM RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: COFACTOR: v r� <br /> FOR DEPART USE ONLY <br /> PHASE I l <br /> APPLICATION ACCEPTED BY: �.�'d, DATE: a a y <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE IIIFINAL <br /> INSPECTION BY: 40111- DATE INSPECTION BY: ► DATE <br /> E H 1426 SAN JOAQUIN FOCAL HEALTH DISTRICT 1/72 ]M <br /> DISTRIBUTION WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWEM - PINK-CONTRACTOR <br />