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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. ' <br /> (Complete in Triplicate) Date Issued: '-a" <br /> HIS PERMIT EXPIRES I 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: <br /> OWNER'S NAME: c CENSUS TRACT: - r <br /> ADDRESS: _ PHONE: 'per p <br /> CONTRACTOR'S NAME: "r CITY: _-1 s c 6 x,f,A/ `— <br /> © LICENSE # <br /> ____--- PHONE: ___$ - <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / 'PUBLIC WATER WELL )/7/_ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL J J <br /> CATHODIC PROTECTION WELL )!J_ GEOPHYSICAL, WELL/_// OTHER /7 <br /> NEW WELL: DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY Y <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> N <br /> REPAIRS: TYPE OF REPAIRS: � � �� <br /> Pi I <br /> r <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 <br /> DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUI , AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> { <br /> PHASE I FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY: rr ' <br /> ADDITIONAL COMMENTS: DATE: U Z1 <br /> i; <br /> PHASE II PHASE III/FINAL rj <br /> INSPECTION BY: DATE INSPECTION BY; Q, DATE 3`;ZD- 7 <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />