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FOR OFFICE USE: LICATION FOR WELL OR PUMP PERM' PERMIT NO. z1--a7� <br /> (Complete in Triplicate) NNW Date Issued• 3 <br /> 'HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> oSoR n,c3 <br /> //( 'liFt/Lee«. <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 SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: �` 2 'r <br /> 9 k�.aat4k7 V,' /K <br /> -w -PJ;5� r CENSUS TRACT: <br /> OWNER'S NAME: - _ ,y �� srr��.e �o PHONE: .,35-e2 <br /> ADDRESS: Itfe Ie CITY: nwc y <br /> CONTRACTOR'S NAME. - � .+oN LICENSE # -j );p3y PHONE: 4�� Sr_ 2y:2-(S <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL l4/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUINDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER 17 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK /,PD SEWER LINES /00 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: �^ <br /> oe <br /> e <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> C <br /> n <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 SAN JOAQUIN, AND THE LES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: LT' l J7 -1- <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/`FFIINNAAL <br /> INSPECTION BY: DATE INSPECTION BY: E' <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />