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r <br /> k FOR OFFICE USE: APPL,,CATION FOR WELL OR PUMP PERMIT PERMIT NO. L -3 JI <br /> .(Complete in Triplicate) Date Issued - � 7z <br /> i HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br /> 4 <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. off_ <br /> f1 327 <br /> .JOB ADDRESS[LOCATION- 450' NIs Jahan'tm'&' i Mi.E. Tully Road CENSUS TRACT: Sy y <br /> .OWNER'S NAME: BLT Vineyards (BoU Legis & GeorgeThayer) PHONE: 599-3714 <br /> ADDRESS: <br /> 9 - <br /> ADDRESS: 3 50,4 Jjgc6uelyn Way, Modesto CITY: <br /> CONTRACTOR'S NAME: p13gYiapce Drillers' - LICENSE # 24.0107 PHONE: 9 'f-f"6$ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL L7 PUBLIC -WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /7 INDUSTRIAL WATER WELL /_/ <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> tNEW WELL: .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY w <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT - OTHER <br /> ,REPAIRS: TYPE OF REPAIRS: <br /> 0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> C ~; <br /> A�r�, <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 /> COUNTY OF SAN JOAQUIN, AND HE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 7 <br /> .SIGNED:w0,;_ � S. - CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIOANCOMMENTID BY: � �r ��.fi� DATE: 4-_d <br /> DDITIONAL <br /> r i <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: VJji4 DATE INSPECTION BY: DATE <br /> E H 1426' SAN JOAQUIN LOCAL HEALTH 'DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />