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FOR OFFICE USE: APPLICAT ON .FOR WELL OR PUMP PERMIT PERMIT N0.7i;iglL <br /> % - (Complete in triplicate) Date Issued: <br /> ' THIS PERMIT EXPIRES I: YEAR",IFROM DATE ISSUED Z 117-7 Y <br /> APPLICATION 'ISHEREBY 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 -JOAQVIN_ LOCAL HEALTH DISTRICT. <br /> 71 <br /> JOB ADDRESS/LOCATION.:" f L D�j ? CENSUS TRACT: <br /> OWNER'S NAME: �,�' <br /> "' PHONE: YKq Te O 0 5 <br /> ' ADDRESS: .` _ `" .<j x y.✓.o �., x c: CITY`: <br /> CONTRACTOR'S NAME ,ms`s �`� f ci _' s: -±� F''t en's LICENSE # PHONE• <br /> .INTENDED, INDIVIDUAL..DOMESTIC WATER WELL iff <br /> PUBLIC WATER WELL. / '/. :TEST-WELL /7 <br /> IRRIGATION/LIVESTOCK./AGRICULTURAL ATER WELL /_INDUSTRIAL WATER WELL L_1 .. <br /> CATHODIC PROTECTION WELL /'J GEOPHYSICAL WELL / / OTHER <br /> :y - �-.�.�c��lti�v_ -a.l '_ �.'+f1 '!:- �_' .•....yam •-lv—w- �{ �F... .rrrlr G. <br /> ,l <br /> NEW WELL: DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY g. <br /> SEWAGE DISPOSAL, FIELD CESSPOOL SEEPAGE 'PIT OTHER <br /> - . <br /> REPAIRS: .TYPE OF REPAIRS.. e.'� , <br /> V V <br /> -ABANDONMENT/DESTRUCTION ,METHOD'"TO BE USED: <br /> . � • . <br /> LE j{f <br /> ,-PLOT-P-LANI.:io-,,,,SHOW-ON,REV.ER'SE,S-IDE,,- <br /> T_ <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. w <br /> SIGNED: + r � �.>, ,. „. ,x.� ' CONTRACTOR: 1 • ';._ <br /> :I-Z'. ' �':FOR DEPARTMENT`USE"ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: c Z 2— <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: , • .0 i <br /> t ' <br /> PHASE II �. .a ...,PHASE-111 FINAL <br /> INSPECTION BY: �DATE y=E INSPECTION .BY:• DATE <br /> E H 1426~ " T = SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 ' 1M' <br /> ' �; <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY-OWNER-.- .PINK-CONTRACTOR <br />