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AOR OFFICE USE: PLICA ON 'FOR WELL OR PUMP PE*11T PERMIT N0. 7 7 1 O <br /> (Complete in Triplicate) Date Issued: <br /> THIS PERMIT EXPIRES I 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 /> ,.. . . <br /> JOB ADDRESS/LOCATION: eo CENSUS TRACT: /.30� fl3a�-fy <br /> OWNER'S NAME . PHONE: <br /> ADDRESS: CITY: _ <br /> CONTRACTOR'S NAME: LICENSE 4f J42,3 73 PHONE: _ f 6 14 25. <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL J / PUBLIC WATER WELLr/ TEST WELL <br />,. IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / J GEOPHYSICAL WELL / / OTHER 17 <br /> o <br /> NEW WELL: DISTANCE T SEWER LINES T PRIVY LD CESEWAGE DISPOSAL (' <br /> SSPO <br /> PAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: f <br /> " h <br />` ABANDONMENT/DE TRUCTION: METHOD TO BE US, D,: <br /> .. <br /> PLOT PLAN: SHOW ON REVERSE SIDE 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: , t <br /> _ CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY, 3 k + <br /> APPLICATION ACCEPTED BY: iJ, DATE: 2- <br /> ADDITIONAL COMMENTS: J <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATEJ INSPECTION BY: DATE �-/0°` � <br /> E H 1426 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 ]M E <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -- PINK-CONTRACTOR <br />