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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 2?-- IF 3 <br /> (Complete in Triplicate) Date Issued: ,,�. z 3- 7 v <br /> THI 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 REGULATIONSS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> r- <br /> JOB ADDRESS/LOCATION: r CENSUS TRACT: <br /> OWNER'S NAME: fl. PHONE: <br /> ADDRESS: g CITY: <br /> CONTRACTOR'S NAME: LICENSE #1 3ZZ PHONE: �3(. <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL /—/ PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL I <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL %/ OTHER /-7 ss <br /> • l <br /> q <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD` CESSPOOL SEEPAGE PIT OTHER. -` <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BEMUSED: ;: # � <br /> I <br /> I ,v <br /> tt <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THATII 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;- <br /> ' CONTRACTOR: <br /> Lu <br /> FOR DEPARTME T USE ONLY <br /> i <br /> PHASE I <br /> (?4f4t;6 <br /> r - (J DATE: �% .71APPLICATION ACCEPTED BY: <br />` ADDITIONAL COMMENTS: <br /> PHASE It <br /> PHASE III/FINAL <br /> k DATE 7 <br />� INSPECTION BY: _ _� _ DATE INSPECTION BY: f _ <br /> �f <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-WEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> R � <br />