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FOR OFFICE-USE: � b APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. , 37� <br /> _—_ (Complete in Triplicate) Date Issued: Jz� <br /> THIS 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 SAND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATI N: `1;70 A24 CENSUS TRACT: <br /> OWNER'S NAME: PHONE: 3/6 <br /> ADDRESS: CITY: <br /> — <br /> CONTRACTOR'S N LICENSE #_fZ PHONE: _ 6 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURA . WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL %/ GEOPHYSICAL WELL—/_/ OTHER _ %/ <br /> NEW WELL: DISTANCE TO NEAREST: SEPT C TANK/0'/SEWER LINES`/PIT PRIVY <br /> SEWAGE DISPOSAL FIELDf�/CESSPOOL SEEPAGE PIT OTHER e <br /> V1 <br /> REPAIRS: TYPE OF REPAIRS: <br /> V <br /> �G <br /> V ' <br /> C <br /> ABANDONMENT/DESTRUCTION: METHOD TO-BE USED: <br /> c� <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 OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF JOAQUIN, AND THE LES AND REGULATIONS OF THE SAN JOAQ"LOCALALTH STRICT. <br /> SIGNED: CONTRACTOR <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE _ INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 2/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />