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PERMIT NO. <br /> 7n.� <br /> USE: APPLICATION FOR WELL OR PUMP PERMIT Date Issued• ) <br /> (Complete in Triplicate) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z_ t Z. 7 i <br /> .. F, pp9—ago-ol <br /> '�r �e�APPLICATt HEREBY MA) , 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 /> . q 49-( CENSUS TRACT: <br /> JOB ADDRESS/LOCATION: � I—'G PHONE' �_ — -2 ��--- <br /> OWNER'S NAME: _, CITY: . <br /> ADDRESS: LICENSE fl /J PHONE: <br /> CONTRACTOR'STEST WELL 1-7 <br /> : <br /> INTENDED USE: INDIVIDUAL STIC WATER WELL L-T PUBLIC WATER WNLUSTRIAL WATER WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL � / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> U1 <br /> 7. <br /> V. b�%1 c <br /> d PIT PRIVY , <br /> N WELL: DISTANCE TO NEAREST'. , SEPTIC TANK. <br /> '.SEWER LINES <br /> OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT // <br /> D <br /> REPAIRS: TYPE OF REPAIRS! ' <br /> x.00` o0 <br /> / e FJT9�NA�( <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> c <br /> Yr . �l�y�t yak <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I <br /> WORR-WILL BE-DON£-IN-�`-'` <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE. THE ORDINANCES OF THE <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE-STATE OF CALIFORNIA, <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAY)UIN LOCAL HEALTH DISTRICT. <br /> CONTRACTOR: , <br /> SIGNED: <br /> p l ` <br /> �I <br /> --FOR T- <br /> -DEPARTMENUSE-ONLY- -" <br /> PHASE 1 _ ^- <br /> APPLICATION ACCERTED BY: <br /> DATE: <br /> ADDITIONAL COMMENDS: <br /> 7 ' <br /> �' - PHASE III FINAL <br /> PHASE II ', <br /> DATE --3-7y <br /> INSPECTION BY: DATE INSPECTION BY: /�/ I/72 IM <br /> E H 1426 SAN JOAfUIN LOCAL HEALTH DISTRICT <br /> DISTRIBUTION: WHITE-BEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> � -- <br />