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FOR OFFICE USE: AP L�-I AT ON FOR WELL OR PUMP PERMIT PERMIT NO'. <br /> -- - (Comp ,ete-in Triplicate) Date Issued: V25117')— <br /> _ <br /> THIS 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 HEREAFTER. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE . <br /> NO. 1862 AND RULES AND REGULATIONS. <br /> JOB f'-ADDRESS/LOCATION: 1D3j &t)/ ���► �"a /y L2& CENSUS TRACT: <br /> OWNER'S NAME: PHONE: At o nim 1 <br /> ADDRESS: CITY: o-a i <br /> CONTRACTOR'S NAME: e/, ( , �t 1 h_d, +�+_�-v- LICENSE # P] '� { PHONE: 1/7 7 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL lK PUBLIC WATER WELL/ / TEST WELL <br /> IRRIGATION%LIVESTOCK/AGRICULTURAL WATER-WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL j_/ GEOPHYSICAL WELL /—/ OTHER L/ I <br /> .i <br /> NEW WELL: DISTANCE TO ST: SEPTIC TANK SEWER LINES PIT PRIVY SEWAGE <br /> .DISPOSAL FIELDIL CESSPOOL/SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> f� I <br /> ABANDON/DESTRUCTION: METHOD TO BE USED: Q <br /> PLOT PLAN: SHOW 0 ; EkSh SIDE <br /> I HEREBY CERTIFY THAT .I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN, <br /> ACCORDANCE WITH SAN -JOAQUIN COUNTY ORDINANCES, STATE -LAWS ANn,,,RULF<,_A_vn_REGULATIONS-_OF' THE_ � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED v � i .� CONTRACTOR: 91VI /^ <br /> ZL: -- <br /> + <br /> FOR DEPAR NT USF .Nj_ <br /> PHASE .I <br /> APPLICATION ACCEPTED BY:- DATE � 7.2-- <br /> ADDITIONAL COMMENTS: _AA% _ <br /> 'yo {SLP-5Ttc- <br /> PHA,,E I•I PHASE III/FINAL <br /> INSPECTION BY: DATE - � — � F,� - - DATE <br /> ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ey H;;:. - <br /> D.,�J y P l� u,-�r - h"`-�'"�`�t4s� - <br />