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PERMIT <br /> -FOR OFFICE USE: ADPL TION FOR WELL pl PUMP PERMIT Date Issued <br /> (Complete in Triplicate) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z- Z z- 7 Y <br /> ,. r oo9_ mo—ol <br /> ,C -751 ALF �L'uu t <br /> APPLICATION J S HEREBY MA) . TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PER <br /> THE WORK STATED HEREON. THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF THE� SAN JOAfQUI�N?L�OC,IA�L HEALTH DISTRICT. <br /> 4f, CENSUS <br /> JOB ADllRESS/LOCATION: ^ � <br /> �H • - <br /> OWNER' S NAME: W, / CITY: <br /> PHONE: <br /> ADDRESS: A: LICENSE # 1% <br /> CONTRACTOR'S NAME: <br /> INTENDED USE: INDIVIDUAL STI WATER WELL L/ PUBLIC WATER <br /> NDUSTRIALTEST <br /> WATERWELL <br /> WELL// / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL <br /> OPAYTIR WELL WEL�/ / OTHER <br /> L/ <br /> CATHODIC PROTECTION WELL / / <br /> ' r <br /> " SEWER LINES PIT PRIVY <br /> NE WELL: ANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL SEEPAGE PIT <br /> VP <br /> I <br /> REPAIRS: TYPE OF REPAIRS: "Lv <br /> s_ <br /> _s / • .- Esc <br /> } � . ,` <br /> AMMONMENT/DESTRUCTION: METHOD TO =BL USED: <br /> I P <br /> ' i <br /> PLOT PIAN: SHOW ON REVERSE SIDE <br /> ` . <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEWORK WILL-BE-DONE-IN— <br /> E WITH THE PROVISIONS OF THE LAWS OF THE.STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> ACCORDANCE COUNTY OF SAN JOOAQUIN, AND T <br /> RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRIC' <br /> CONTRACTOR: ' <br /> SIGNED: _ I <br /> —_ FSO.�R"�DjE�PARTM£NT"USE'DNLY-"_-;�- - _ <br /> PHASE I - <br /> � DATE: <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: <br /> y <br /> PHASE III FINAL <br /> PHASE II <br /> iG IINSPECTION BY: liC/ DATE } -3 <br /> DATE -�y <br /> INSPECTION BY: - 1/72 11 <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT <br /> - PINK-CONTRACTOR <br /> nremnTRirrTnN: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER <br />