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FOR OFFICE USE: APPLICATI FOR WELL OR PUMP PERMIT PERMIT NO 2 - 9 <br /> (Complete in Triplicate) Date Issued: ,? -/ 7 7­. <br /> IS 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. 1$62 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> ,JOB ADDRESS/LOCATION: ~�1 CENSUS TRACT: <br /> OWNER'S NAME: PHONE: <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: (, . LICENSE # PHONE: <br /> INTENDED USE: INDIVIDUAL .-DOMESTIC WATER WELL /y_�_ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /_7 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER /_7 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> i <br /> REPAIRS: TYPE OF REPAIRS: .fir i <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> PLOT PLAN: SHOW ON REVERSE SIDE I <br /> I <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 /> ,. , � <br /> SIGNED: , CONTRACTOR: J " ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYv DATE: _ _ G <br /> ADDITIONAL COMMENTS: / I <br /> --� <br /> ATE/-HEALTH <br /> PPHASE II FINAL <br /> INSPECTIONDATE ' INSPECTION BY: P DATE <br /> E H 1426SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTI DISTRICT - YELLOW-PROPERTY OWNER - XINK--CONTRACTOR <br />