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FOR OFFICE USE: PUMP PERMIT PERMIT N0. L 5� r (Complete in Triplicate) Date Issued HIS`PERMIi EXPIRES I YEAR FROM DATE ISSUED APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE I NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT, JOB ADDRESS/LOCATION: " F OWNER'S NAME: CENSUS TRACT: r ADDRESS; �� 'PHONE: � ,=? d-- -y5' CONTRACTOR'S NAME: LICENSE 4E PHONE: • ' PHO INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL /% PUBLIC WATER WELL f TEST WELL / IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / J_INDUSTRIAL WATER ' CATHODIC PROTECTION WELL /% GEOPHYSICAL WELL / f OTHER 1 NEW WELL:_ DISTANCE TO NEAREST: SEPTIC T�iNK .` SEVER.LINES` PIT PRIVY SEWAGE D SPOSAL FIE D" CESSPOOL SEEPAGE PIT OTHER/ T.-17'Z REPAIRS, TYPE 4OF REPAIRS: �)(d �-�r 1i_1��J f' + a Gly �-o-�/ it (,ti,[ •� � Qi}f � `,ry--f ��'. /J{'� �� "�1, �.r 114,.0.{�� 1 1` r t ,7lb , ) , ABANDONMENT/DESTRUCTION: METHOD TO BE USED: / t PLOT PLAN: SHOW ON REVERSE SIDE" _ s i. 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 TH DISTRICT. 1 _ ✓fC c p�, 4 _ f SIGNED: ) , ✓, CONTRACTOR: `�— ": • Ftp ��= 1 I � � � _� E FOR DEPARTMENT USE ONLY PHASE I APPLICATION ACCEPTEDBY: f _ DATE: -� ADDITIONAL COMMENTS: i PHASE II PHASE III FINAL INSPECTION BY: DATE INSPECTION BY: DATE E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT lbijfj DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR 1172