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I FOR,OFFI6E USE: <br /> rAPPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT NO. 7 Z -"7' 7 <br /> (Complete in Triplicate) Date Issued-:74- _ <br /> IT EXPIRES I YEAR FROM DATE ISSUED . 7 L <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 N <br /> I 'LOC EALTH DISTRICT. <br /> ;TOBDRESS/Lac TION: :►.,.,� ' <br /> OWNER'S NAME: CENSUS TRACT: 05Z5'.-._f-1-OS <br /> Q z,�, -' PHONE: <br /> ADDRESS: <br /> j <br /> CONTRACTOR'S NAME: CITY: <br /> LICENSE # � L PHONE: <br /> INTENDED USE: INDIV DUAL.DOMESTIC WA�y,L /% PUBLIC WATER WELL <br /> /�/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WE'LL <br /> t CATHODIC PROTECTION WELL / /. GEOPHYSICAL WELL / / OTHER / <br /> NEW WELL: DISTANCE TO --� ST; TANK SEWINES PI VY <br /> SEWAGE DISPO IELD CES SEEPAGE PIT OTHER '------------------------ <br /> J <br /> t <br /> REPAIRS: TYPE OF REPAIRS: <br /> f , v <br /> E. <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 4 <br /> i <br /> 1 <br /> R <br /> PLOT. PLAN: SHOW ON REVERSE SIDE _ <br />-:J-HEREBY_ CERTIFY THAT I HAVE PREPARED THIS APPLICATION-.AND.THA-T THE :WORK,WILL-BE DONE-1-N- <br /> .1 <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. F <br /> SIGNED: ei . ' CONTRACTOR: <br /> P FOR D PARTMENT USE ONLY <br /> HASE I <br /> APPLICATION ACCEPTED BY: D 2 <br /> ADDITIONAL COMMENTS: ATE: �� <br /> t, (IV ' <br /> PHASE II 1 <br /> ZPHHA,SE III/FINALINSPECTION BY: DATE INSPECTION BY: DATE _3-rP- VZ. <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT• • <br /> DISTRIBUTION: WHITE–HEALTH DISTRICT – YELLOW-PROPERTY OWNER – PINK–CONTRACTOR 1172 IM <br />