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�,� f <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete in Triplicate) Date Issued: 3-f—.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> 06 5.- 2-ao--o y <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: Pit 3 Pox 140) Galt, Gal`tf.(See map) CENSUS TRACT: ' S <br /> ,OWNER'S NAME: Jahn Kenefick PHONE: <br /> .ADDRESS: Rt. 2 Pox 14 9. Galt Ca if. R 2 CITY: <br /> CONTRACTOR'S NAME: turviance Drillers Box 64, LICENSE Z0107 PHONE: 931- 68 <br /> Linden, G-Rl.x f. 95236 _ <br /> INTENDED USE: INDIVIDUAL-DOMESTIC WATER WELL /7 PUBLIC WATER WELL / / TEST WELL /_7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> `NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY' <br /> SEWAGE DISPOSAL FIELD 3GESSPOOL SEEPAGE PIT OTHER a_ <br /> REPAIRS: TYPE OF REPAIRS: Clean well of sana <br /> r <br /> I� ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> k <br /> i <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 TH RU ES REGULATIONS OF T E SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> �E,f� bGt�` ,��u+/f�sP ®Lvf7 B'rS fh�D-�*rdy-✓ate , . <br /> SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE: "7"` L <br /> APPLICATION ACCEPTED BY: L . <br /> ADDITIONAL COMMENTS: 3 ' <br /> PHASE 11 PHASE. III FINAL <br /> E INSPECTION BY:- _ 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 />