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r FOR-OFFICE USE: AP ;CATION FOR WELL.-OR PUMP PERMI PERMIT NO. / <br /> {ComQlete in Triplicate) Date Issued:z LL -72- <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED — <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: ��� //�1 <br /> ��✓� CENSUS TRACT: » . <br /> OWNER'S NAME: vy� .� O t PHONE: <br /> ADDRESS: G` CITY: <br /> CONTRAC <br /> TOIr S NAME: LICENSE #.Ze PHONE: <br /> 7r acv _ <br /> INTENDED USE: INDIVTDIIAT WATER WELL /7 PUBLIC WATER WELL A< TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL j/ / GEOPHYSICAL_WEL,L / / OTHER J_/ <br /> i <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 /> ti. <br /> 4. <br /> 14 <br /> ABANDONMENT/DESTRUCTION: ' METHOD TO BE USED � r.1. w <br /> & 1 <br />_ - u <br /> u <br /> HOW. ON REVERSE- SIDE <br /> s>� <br /> PLOT PLAN: ` S <br /> 4. <br /> I HEREBY CERTIFYTHATI HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 1319-"DONE IN <br /> ACCORDANCE WITH THE PROV OF THE LAWS OF-THE STATE OF CALIFORNIA, THE ORDINANCES OF .THE <br /> COUNTY OF SAN JOA THE AND RE ATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. x <br /> SIGNED: *CONTRACTOR: �� _ <br /> r si. rtr Ar .4' ! - ;; .,., c:C�. - „ - , -_.�'ti „t'a E •r J'; �l. <br /> FOR DEPARTMENT USE ONLY `a <br /> PHASE I 3. <br /> _ c _ _:, '� -'r �. . � ».� _ ` ice:•.- ; t r �^� ... ': C � 1 <br /> APPLICATION ACCEPTED BY: <br /> ADDITIO w DATE <br /> NAL COMMENTS: <br /> 4. <br /> h r �ar I <br /> PHASE II <br /> r FINAL <br /> INSPECTION BY: ' 3 ZDAT <br /> k INSPECTION BY: DA <br /> TE° {" <br /> E H 1425 , _v <br /> t '; AN JOA VIN LOCALHEALTH DISTRICT.. - "_ T/72 <br /> 3ISTRI�TTION WHITE HEALTR DISTRICT YELLOW PROPERTY.,.OWNER - PINK- O TOR <br /> jr t4 1!a <br />._. ..,... ....,<,.. i_ 14 ,..,cv 2,11Y ....f•]4•� .,.....l:•,.,..... ,.�I 1,....�....1..•....v. ..., ,.,.a... <br />