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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 7 Z 3 5 <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7Y7/ ( <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 COMPIaIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: Jac Tone Rd-' north of -Lone Tree CENSUS TRACT: <br /> OWNER'S NAME: 1 Luck ,,McFall , Jr. PHONE: 982-1470 <br /> ADDRESS: 13918' 3. Jack Tone CITY: Stockton <br /> CONTRACTOR'S NAME: John Panero LICENSE 11125724 PHONE: 5 -7570 886-5400 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /_7 — <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL A,1 INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> i <br /> a <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> e <br /> REPAIRS: TYPE OF REPAIRS: Deepening 16" well ,from 581 � r <br /> w ® L D <br />� T�R o <br /> 1.q , <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> i <br /> 4-7.3 NO 50MI Tib 51r L <br /> k <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 /> i COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> °�i ` <br /> i APPLICATION ACCEPTED BY: 0 . �- <br /> DATE: 2-- <br /> k ADDITIONAL COMMENTS: <br /> V <br /> F PHASE II PHASE III/FINAL <br /> DATE <br /> INSPECTION BY DATE _ INSPECTION BY: _. <br /> E H 1426 SAN JOAgUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />