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i r PERMIT NO. 'FOR OFFICE USE: �IQN FOR WELL OR PUMP PERMIT Date Issued: (Complete in Triplicated , THIS PERMIT. EXPIRES I YEAR FROM DATE ISSUED Z-_ z y 7'' E 009—�0-01 FOR A pERKIT TO APPLICATION4, RICT IS HEREBY MAB , TO RM Ty THE SAN JOAQUIN LOEALNH COMPLIANCE TH COUNT`j ORDINANCE O THE WORK STATED'HEREON• THIS APPLICATION IS N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. CENSUS TRACT Hu JOB ADDRESS/LOCATION: J PHOKE: OWNER'S NAME: , CITY: ADDRESS: LICENSE J y D PRUNE: ' ii `fes CONTRACTOR'S N L ( f'. TEST WELL J-7 PUBLIC WATER WELL I 1 INTENDED OSE: INDIVIDUAL STIC WATER WELL /CATER WELL _INDUSTRIAL WATER WELL /� IRRIGATION/LIVESTOCR/AGRI�T�L / F► 1/ CATHGEOPGEOPHYSICALYSZCALODIC PROTECTION WELL L/ Ul r . r7t• {l1 SEWER LINES PIT PRIVY E DISTANCE To ST.. SEPTIC TANK N WELL: • � CESSPOOL SEEPAGE PIT OTHER SEWAGE DISPOSAL FIELD _ S REPAIRS: TYPE OF REPAIRS' .00 $L USED: ABANDONMEN�/DESTRUCTION: METHOD TO y ! 9 i B ; " PLOT PLAN- SHOW ON REVERSE SIDE ' WOR3C WILi-BE-DOty$—IN THIS APPLICATION AND THAT Tom' TAE ORDINANCES OF THE I HEREBY CERTIFY THAT I NAVE PREPARED WS OF THE-STATE OF CALAI� IN LOCAL HFA,TH DISTRICT. ACCORDANCE WITH THE PROVISIONS OF THE TIONS OF THE TEE RULES AND REGULA COUNTY OF SAN 30AQUIN. CONTP TORN � _ SIGNED: G -�OR-DEPARTMENT-USE-0NLY"''"-- .✓' PHASE I DATE: APPLICATION ACCEPTED BY: ADDITIONALC6 M NTS: y . P13ASE III FINAL q PHASE 1Z DAT -3-7 3-- DATE INSPECTION Byl- ____��.� --- --1/72 1MINSPECTION BY: SAN JOA IN LOCAL HEALTH DISTRICT PINK-CONTRA CTOR E R 1426 Tg DISTRICT - YELLOW-PROPERTY OWNS - DISTRIBUTION: WRITE-�' -