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FOR OFFICEUSE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7Z- 1 S 7 <br /> (Complete in Triplicate) Date Issued: '-:3. -Z_?--7 <br /> T S 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: U -77 ,✓ o ,�'' a e/ CENSUS TRACT: <br /> OWNER'S NAME: _ �` PHONE: _._.2f ol _ _Z <br /> ADDRESS: ? o h ��G CITY: <br /> Eilrrs� r <br /> CONTRACTOR'S NAME: �f- ,�. "' r, CENSE a 2.-L(.-`PHONE: !116 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL L7 PUBLIC WATER WELL /—/ TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL A-7 INDUSTRIAL WATERWELL L-% <br /> CATHODIC PROTECTION WELL/IT GEOPHYSICAL WELL L7 OTHER /_7 <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: — <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-4F THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF IN AND THE RUL S AND REGU ONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> Ik _ - <br /> SIGNED: <br /> 71 1- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: i ' DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY:agEa� ATE �- (D 7 Z <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT -77-zj 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER —PINK-CONTRACTOR <br />