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- - - <br /> i PERMIT NO. Z� <br /> 'FOR OFFICE USE: ADPL TION FOR WELL OR PUMP PERMIT Date Issued• <br /> (Comp4- <br /> lete in Triplicate) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L- 7- 2-- 72-- '## <br /> 00 g--tr7 0—01 1 <br /> s.� s-7 5 E = �� <br /> APPLICATION J HEREBY , TD THE SAN JOAQ[3IN LUCAINHEALTH <br /> COMPLIANCE WITHFCOUNTY ORDINANCE <br /> THET TO THE WORK STATED' HEREON. THIS APPLICATION IS MADE <br /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUI//N LOCAL HEALTH DISTRICT. <br /> CENSUS TRACT: <br /> JOB ADDRESS/LOCATION: �`� ���`' PHONE: <br /> OWNER'S NAME: CITY: _ <br /> ADDRESS: P ' i f a PHONE: <br /> , '. LICENSE P r J -, — <br /> CONTRACTOR'S N E: - l r _ <br /> INTENDED USE: INDIVIDUAL ESTIC WATER WELL I I PUBLIC WATER WELL / I TEST WELL / <br /> IRRIGATION/LTVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL /E/ < cTM <br /> _1 <br /> CAT <br /> PROTECTION WELL <br /> �, / / GEOPHYSICAL WEL / / OTHER <br /> A <br /> ".SEWER LINES PIT PRIVY NE WELL: DISTANCE TO NEAREST: SEPTIC TANK, <br /> SEWAGE DISPOSAL FIELD _ CESSP00L SEEPAGE PIT OTHER' <br /> - x <br /> XIL <br /> REPAIRS: <br /> TYPE OF REPAIRS: ' "o <br /> d"C1�LP� <br /> ,E <br /> ABANDDNMENT/DESTRUCTION: METHOD TO :BE USED: <br /> f r: <br /> PLOT PLAN: SHOW ON REVERSE SIDE ���� <br /> f , <br /> 3 { <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE-WORK <br /> RTHE ORDINANCES <br /> THE <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE NS OF OF CALIFORNIA, <br /> COUNTY OF, SAN JOAQUTN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> + , r CONTRACTOR:, <br /> SIGNED. <br /> FOR-DEPARTMENT-USE_ONLY""__:. <br /> PHASE I <br /> i DATE: <br /> APPLICATION ACCEPTED BY* <br /> ADDITIONAL COMMENTS: <br /> !3 PHASE IIT. FINAL <br /> PHASE II <br /> INSPECTION BY: � DATE `3"7 Y <br /> INSPECTION BY: DATE 1/72 LM <br /> ` SAN JOA UIN LOCAL .HEALTH DISTRICT <br /> E H 1425 <br /> ;DISTRIBUTION: WHITE-HEALTH DISTRICT Y <br /> E <br /> LLOW-PROPERTX OWNER - PINK-CONTRACTOR <br />