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FOR OFFICE USE: APPLICATIONfFOR WELL OR PUMP PERMIT PERMIT NO. -7 2-'l L d (Complete in Triplicate) Date Issued: 3. ! 7 z— THIS PERMIT EXPIRES i YEAR FROM DATE'ISSUED F APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM I THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE k NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. JOB ADDRESS/LOCATION: L6j 2,35?L_ &A R (V ry G 1y G G fG]1 CENSUS TRACT: OWNER'S NAME: �To c.eAf 41rf/K G,s . .,., ....,,.,. ,.,........_..._...._ PHONE: _AiS�-4e ADDRESS: CITY: CONTRACTOR'S NAME: G4:AI1V,6r ft SAi—_ S� GyLICENSE # SG r7,61 PHONE: V4. U 9-:3 f'_----- INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL X' PUBLIC WATER WELL / J TEST WELL IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER y NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' REPAIRS a TYPE OF REPAIRS: X A/17A L 1- 5!h° 3 ce,B o V j ( .f � c�.tA.P�� t 4j6J�44 -- � f ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � r ' r r PLOT PLAN: SHOW ON REVERSE1SIDE l I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE } COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. SIGNED: ZZ d' CONTRACTOR: r FOR DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTED BY: DATE. ADDITIONAL COMMENTS: PHASE II PHASE III FINAL INSPECTION BY: s. DATE INSPECTION BY: DATE E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/. 72 1M DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR k