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_ Y XO <br /> - P pI Date Issued:z <br /> - "CATION FOR WELL OR PUM <br /> CE USE: AP (Complete in TripxicaCe) <br /> S<1 YEAR QOM DATE ISSUED. <br /> 'IRIS PERMIT EXPIRE <br /> LTH DISTRICT FOR A PERMIT TOCEEORM <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEA <br /> E IN COMPLIANCE WITH COUNTY ORDINAN <br /> GTIONS OF THE SAN 30AQUIN LOCAL HEALTH DISTRICT. <br /> HE WORK STATED Lj{ERE <br /> ON. IS AP <br /> TPLICATION IS . <br /> NO. 1$62 AND R CENSUS TRACT. - <br /> f ✓2- ✓� P HONE: <br /> SOB ADDRESS/LOCATIOl3. 3� O t CITY: <br />, OWNER' S NAME: dt ra./ PHONE: <br /> ADDRESS: G LICENSE ..Z D 4? <br /> CONTRACTO S NAME. 7.23 B3 <br /> ` l�Ls `i�..�*w-.. TEST WELL <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATERC <br /> WELL JLIW TER PUBLIC <br /> ELL ICI IMVSTRIAL WATER WELL I <br /> IRRIGATION/LIVESTOCKIAGRI GEOPHYSICAL WELL / / OTHER / <br /> CATilODIC PROTECTION WELL. / ' <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 /> ' Post-It'"brand fax transmittal memo 7671 #of pages ,, <br /> - TO From <br /> �[ 0. <br /> Pus <br /> ll /Sc�Z f <br /> Dept. I Phone1 �U'-7 <br /> ABANDONMENT/DESTRUCTION: METHOD, FaxS/U /' b S� Fax# <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 PRO OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOA THE AND RE TIONS OF THE SAN JOAQUIN LOCAW HEALTH:DISTRICT. <br /> SIGNED: = CONTRACTOR: e2 <br /> Y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: " <br /> ADDITIONAL COM ENTS: <br /> 4 II <br /> P PHASE ! 1 /FINAL .. <br /> — E II ' p -t <br /> INSPECTION BY: 3 ZnAT INSPECTION BY: !1 DATE <br /> H 1426 ,_:.._. _..:.: .. . '1� — 4 <br /> AN' JOA IIIN LOCAL HEALTH DISTRICT' :;'' , _ `�_-".~: _..Y;...: 1/77. <br /> I5TRI&ITxON:.''WHITE�.HEALTH DISTRICT..-,.YELLOW—PROPERTY OWNER — PINK 0 R. ': <br />