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Y S ! <br /> FQR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z- 1 <br /> (Complete in Triplicate) Date Issued: - 7?� <br /> THIS PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBYMADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON. THI5 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: ' 6363 E. Main St. CENSUS TRACT: <br /> OWNER'S NAME: isoes ersen PHONE: <br /> ADDRESS: ine CITY: <br /> CONTRACTOR'S NAME: amer Coo LICENSE # PHONE: #11 1858 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL f*1 PUBLIC WATER YELL / / TEST WELL /7 __.. <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / I INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /. / GEOPHYSTC&L, WELL / `/ OTHER <br /> -�F ._.IJG y► Y L-�W[•.1.V�YC._a 'aL air___. _ .. <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . , CESSPOOL S '"" <br /> EEPAGE. PIT -u'OTHER <br /> No sewage disposal; ins=alred 'as- yet. <br /> REPAIRS: TYPE OF REPAIRS: .Drill and case 6 inch well and install 1 hp submersible pump <br /> E " <br /> for pressure system. t <br /> t W . <br /> IT) . <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED;: <br /> 3 <br /> t � <br /> PLOT PLAN: SHOW ON REVERSE SIDE ` <br /> 1 <br />-I HEREBY CERTIFY THAT I HAVE REPARED'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 THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: ,�.�„lvs i.� CONTRACTOR , c <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: /Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: i 1 A E 46 99-` r <br /> E H 1426 47SAN JOAQUIN "LOCAL HEALTH DISTRICT 3/72 1M � <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />