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FOR OFFICE USE: APPLICATIONFOR WELL OR PUMP PER�ANT NO. <br /> (Complete in Triplicate) Issued: <br /> IS PERMIT EXPIRES 1 <br /> VHYEAR FROM DATE ISSUED <br /> 2-'r-0 0 / <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: _ Z milw West of cor. Mueller and Stark rdCENSUS TRACT: <br /> OWNER'S NAME: Anna Vierra & Sons *- . PHONE: 463 7081 <br /> ADDRESS: 4553 S. Inland Drive Holt Calif. CITY: <br /> CONTRACTOR'S NAME: J. A. Thalhamer Co. LICENSE # 272303 PHONE: 477 1858 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /_7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL YW' <br /> CATHODIC PROTECTION WELL /-/ GEOPHYSICAL WELL / / OTHER /_7 <br /> This well to be used for washing asparagras only. <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 120ftSEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT _ OTHER <br /> O <br /> N <br /> REPAIRS: TYPE OF REPAIRS: S <br /> cM <br /> t` <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 1 <br /> �t <br /> PLOT PLAN: SHOW ON REVERSE SIDE <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: r �� A ca_( ,.,..,�` CONTRACTOR:y, <br /> FOR DEPARTMENT USE ONLY (J <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: Z <br /> ADDITIONAL COMMENTS: <br /> PHASE IItt,,11 PHASE III FINAL <br /> W <br /> INSPECTION BY: DATE INSPECTION BY: .a iA/q DATE 3 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />