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It.l1t t3[�E'ICE USE: - APPLICATION FOR. WELL OR PERMITII J. _ <br /> (Colaplete in Triplicate) DATE ISSUED* <br /> THIS PERMIT-EXPIRES I- YEAR FROM DATE ISSUED <br /> Y <br /> APPLICATIO-0 IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT EOR A PERMIT TO PERFORM THE <br /> WORK STAVED ND <br /> HEREAFTER. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ©RDI ANCE NO. <br /> RULES AND REGULATIONS. ' <br /> .708 ADDRESSAA) N: D� _ -a. CE�iSt3S TRACT: <br /> OWNER'S NAME" NE: <br /> ADDRESS: - CITY: �---- <br /> CONTRACTORS NAME: <br /> LIENSE #: PHONE:: <br /> C <br /> INTENDED _USE: INDIVIDUF14MLSTIC WATER WELL �/' PUBLIC WAFER DELL j!/ TEST WELI. <br /> f IPRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL d 11NDUSTRIAL WATER WELL / <br /> CATHODIC PROTECTION WELL ! I GEOPHYSICAL WELT, I7 OTHER 7 <br /> (PLOT PLAN: SHOW SIZE OF LOT, LOCATION OF WELL IN RELATION TO SEPTIC SfSTEM, OTffk MEANS OF <br /> POLLUTION, ]ETC. SHOWN ON REVERSE SIDE). <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 0r SEWER LINES jOPI7C PRIiI}� 5.g./SM <br /> DISPOSAI <br /> FIELD CESSPOOL/SEEPAGE PIT OTHER MEANS OF POLLUTION-SURFACE DRAINAGE OR <br /> SUBSURFACE WHAT? - <br /> (WELT, DRILLER'S REPORT-FOR14 N0. MUST BE FILED WITH THE SAN JOAQUIN LOCAL HATH DISTRICT ON <br /> ALL NEW OR RECONDITIONED'WELLS). <br /> REPAIRS: TYPE OF REPAIRS: <br /> (9m. RULES AND REGULATIONS FOR COVERING WELL AND DI5IPIFECTI f oG. SECTION �• <br /> ABANDON/DES VUCTION: METHOD TO BE USED: � - ---_ <br /> (SEI; RULES AND REGULATIONS ItEGARDING AB,ANDON2&NT AND DESTRUCTION). p <br /> Y HEREBY CERTIFY THAT I HAVE �PRE:PARED TRIS APPLICATTON AND TIM THE WORK W7ILL l3R DONT. INA CORD <br /> Ab= WITH SAM JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF THE SAi�T JOAQUIN <br /> LOCAL HEALT . ISTRICT. <br /> SIGNED: ' CONTRACTOR: - � � 'TITLE' <br /> HOWL 0I . OR AGENT CERFOLLOWING: <br /> "T CERTIFY THAT IN THE PERFORNANCE OF TI7E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT <br /> EMPLOY ANY PERSON ,IN SUCH MANNER AS TO BECO14E SUBJECT TO WORIO•'IAN'S COMPENSATION LAWS OF <br /> CALIFORNIA'. <br /> SIGNED: r OWNER <br /> BY: TITLE: -- <br /> 0 TITAN OWNER) <br /> FOR DEPAR T USE ONLY _ <br /> APPLICATION ACCEPTED B`Ar: `f- DATE; ---`� , T 2- <br /> ADDITIONAL C0*1ENTS <br /> � <br /> �-� -� DATE:FINAL INSPECTION BY: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7171 - 3.Oo <br />