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FOR OFFICE USE: APPLI A ION FOR WELL OR PURI' PERMIT PERMIT N0. 7L-1L5 <br /> (Complete in Triplicate) Date Issued: . 7 I <br /> S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO;= 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 -` 12622`Ee Harney Lane] CENSUS TRACT: - <br /> OWNER'S NAME: George W. Hames PHONE: 478 4309 <br /> ADDRESS: ... <br /> - ' 1211. E* Iris,- . -< �. _ - -- -- . CITY: Stockton <br /> CONTRACTOR'S NAME:` . J. Ae Lhalhamer Co. ti LICENSE # 272 303 PHONE: 477 1958 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / "PUBLIC WATER WELL / / TEST-WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /. / .'OTHER / / <br /> Y — .�.. �,- IJ <br /> t <br /> J <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 80ftgEWER LINES 80f't$IT PRIVY <br /> SEWAGE DISPOSAL FIELD80 ft.CESSPOOL SEEPAGE PIT OTHER ' k <br /> REPAIRS: TYPE OF REPAIRS: Drill and case six inch well. Owner to install his <br /> owxi' pressure system <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � <br /> s <br /> w � <br /> i 1 ij <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: <br /> M <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I E -. <br /> APPLICATION ACCEPTED BY: DATE: "7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE o3 3c� INSPECTION BY: DATE <br /> E H 1425 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />