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FOR OFFICE WE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. -Z1 <br /> (Complete in Triplicate) Date Issued: <br /> XHIS 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 HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: 1 _ % u_ Ltd, ,,, ! CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: 1947 'L. CITY: ¢( `r,c �,: <br /> CONTRACTORS NAME: LICENSE # PHONE: 16 4 �4 2.5 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /—/ PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL g INDUSTRIAL WATER WELL /7 <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO � ST: SEPTIC--T SEWER LINES PIT PRI <br /> SEWAGE DISPOSSAL D CESSPOOL PAGE !PIT <br /> REPAIRS: TYPE OF REPAIRS: 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: t �1 <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 SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: .F ��r, P,u� :- 4 041dL, (r. ,r ; CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ; / � DATE: "t <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: C ' DATE 6''l Z- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />