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FOR OFFICE USE.' ` <br /> APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. _5 5 <br /> (Complete in Triplicate) Date Issued: ? <br /> HIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Ct cf 5 7 <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- ("� °p';°"^`- `r jfG r CENSUS TRACT: j 03 Z.�rO-f <br /> OWNER'S NAME: � � `' �--- <br /> L7i ccr PHONE: <br /> i <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME:- �. AQ,,,�: .-- p �,�i LICENSE LAp PHONE <br /> INTENDED USE: INDIVIDUAL :DOMESTIC WATER WELL r PUBLIC WATERao� <br /> nC WELL / / TEST WELL 1-7 <br /> IRRIGATION/LIVESTOCKJAGRICULTURAL WATER WELL /-/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL /% OTHER f <br /> E WELL: DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER- <br /> I <br /> REPAIRS: TYPE OF REPAIRS: i C7 <br /> E .do�i 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <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 SANAQU N, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY: C.C/ // DATE. <br /> ADDITIONAL COMMENTS: -� <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: k DATE INSPECTION BY: DATE g 1,0 lc�_ <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRIC 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER PINK-CONTRACTOR <br /> f <br />