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e; Y j/—,, ¢iN <br /> FOR O FACE"USS: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> (Complete. in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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: i CENSUS TRACT: L _� <br /> OWNER'S NAME: ,{ PHONE: Z, _ .3/ <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: LICENSE # PHONE: °G G. 9�A 3 <br /> k <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL •,•/• INDUSTRIAL WATER WELL /-7 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL/ OTHER 17 <br /> NEW WELL: DISTANCE TO ST: SEPTIC SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL CESSPOOL EEPAGE PIT OT <br /> E � i <br /> REPAIRS: TYPE OF REPAIRS. <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE <br /> PLOT PLAN. SHOW ON REVERSE SIDE <br /> r <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 THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT.. � <br /> SIGNED: - u, CONTRACTOR: <br /> kq <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .{ <br /> APPLICATION ACCEPTED BY: /e, DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE�^I�II/FINAL <br /> INSPECTION BY: DATE INSPECTION BY:71 1 DATE - <br /> E H 1426 - SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72. 1M <br /> DISTRIBUTION: WHITE--HEALTH DISTRICT YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />