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1 FOR OFFIGE'_/USE: APPLE ATTON F WELL OR PUMP PERMIT PERMIT NO. <br /> i(Complete` in ,Triplicate} Date Issued., -J <br /> THIS PERMIT EXPIRES' l YEAR FROM DATE ISSUED <br /> ,APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATERULHERE�•REGTHIS <br /> ULATIflNSAPPLICATION <br /> THE SAN�JDE IN OAQUIN�LOGAL HEALTH DISTRIMPLIANCE WITH CT. � <br /> -Nfl. 1862 AND - <br /> CENSUS <br /> TRACT: S <br /> „TOB .ADDRESS/LOCATION: 20868 N, HWY 99 PHONE; <br /> OWNER'S NAME: Mrs� 'Vio a Crusos CITY: <br /> .ADDRESS: 20568 N Hw Acampos Calif. PHONE: 31- 68 <br /> CONTRACTOR'S NAME: P via <br /> Dri er 4 b LICENSE 0121 07 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL J_ — <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /?=INDUSTRIAL WATER WELL / / <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL C/ OTHER <br /> IInknoovn � -•--. <br /> vEW WELL: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PRT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: Install Customer Pump <br /> i <br /> f- <br /> , oar <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> 11 <br /> E 1. f <br /> PLOT PLAN: SHOW ON REVERSE 'SIDE' <br /> T-I HAVE'1'REPAREII T1 I APPLICATION THAT- —THE WORK WILL BE <br /> 't I"HEREBY-CERTIFY-THA <br /> f IONS OF THE 'LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES THE <br /> E WITH THE P <br /> COUNTY OF J QU TH RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> ACCORDANC <br /> CONTRACTOR: Purviance Dril ers <br /> SIGNED: <br /> - F <br /> # FOR DEPARTMENT USE ONLY <br /> E <br /> PHASE I / <br /> APPLICATION ACCEPTED BY: j V DATE-. IIL7 <br /> ADDITIONAL COMMENTS: <br /> � <br /> PHASE II PHASE III FINAL <br /> 1DATE /l� <br /> INS <br /> INSPECTION BY: DATE <br /> INSPECTION BY: ! — <br /> ~ � SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 <br /> E H 142611 <br /> DISTRIBUTION: WHITE-HBALTH,DISTRICT - YELLOW-PROPERTX OWNER - PINK-CONTRACTOR <br />