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FOR WELL Olt PUPIL PERMIT PERMIT NO.FOR OFFICE USE: �APPLICATIONDate Issued: _5 7 (Carnplete �.n Triplicate) , THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p APPLICATION IS HEREBY MADE TOiTHE SAN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM APPLICATION I5 HEREBY MADE TO•THE 5AN JOA Q THE WORK STATED HEREON. THTSIT _ COMPLIANCE OEDINANGE NO. 1862 AND RULES AND REGULATIONS OFTHE SAN JOAQUINLOCAL HEALTH DISTRICT. ) /I-�Q5 I? JOB ADDRESS/LOCATION: CENSUS TRACT C� PHONE: OWNER'S NAME: ! � � CITY: ADDRESS: U PHONE: LICENS CONTRACTOR'S NAME: _ PUBLIC WELL ST INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL WATER WELLAJEJ INDUSTRIALEWATERLWELL I/ I + IRRIGATION/LIVESTOCK/AGRICULTU L'} CATHODIC PROTECTION WELL J 1 GEOPHYSICAL ... - _ f' (� SEWER LINES.. PIT PRIVY NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK - SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT;,. OTHER REPAIRS: TYPE OF REPAIRS: 4 � ABANDONMENT/DESTRUCTION: METHOD TO BE USED: �. N6 ` ------------------------- PLOT PLAN: SHOW ON REVERSE -SIDE f 1 . 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 QUI OC HEALTH DISTRICT: AND REGULATIONS OF THE SAN JOA ^ CONTRACTOR: s SIGNED: FOR DEPARTMENT USE ONLY PHASE I DATE: APPLICATION ACCEPTED BY: 1%__ ADDITIONAL COMMENTS: `� PHASE III FINAL PHASE II J r INSPECTION BY: DATE S`l� IN BY. DATE I/72 �"1 t E H 1426 I SAN JOA UIN LOCAL HEALTH DISTRIC iK DISTRIBUTION: WHITE--HEALTH DISTRICT — YELLOW--PROPERTY OWNER — PINK—CONTRACTOR �f�;