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FOR OFFICE USE: 5 APPLICATION FOR WELL OR PUM1, PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: <br /> // THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iIX <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: D,JO�- x4 / - _ _ <br /> OWNER'S NAME: 1�. (�,� � �`"`-" '''�CENSUS PHONE: e, , e 2 X S� <br /> ADDRESS: 0 , i F; CITY: Q <br /> CONTRACTOR'S NAME: LICENSE #44 Z 2,7 2 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /_ _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER / / <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> �1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> A3 <br /> b <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 RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: dle , <br /> PHASE I <br /> FOR DEPARTMENT /USE ONLY <br /> �) <br /> APPLICATION ACCEPTED BY: /� %"f' � ; � ,�,�.�,�' '. . /' J DATE: -� <br /> ADDITIONAL COMMENTS: 7— <br /> , <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />