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"FOit' QFFICF��t{SE:" '/� • _ <br /> APPLICATION FOR WELL OR PUMP PERMIT <br /> PERMIT NO. <br /> (COmplete in Triplicate) <br /> HIS PERMIT Date Issued. <br /> EXPIRES I YEAR FROM DATE ISSUED 72' „• <br /> APPI:ICATIQN SIS HEREBY MADE TO °} <br /> »THB CfM4'1TATED% T� SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT T0.PERFORM �`# <br /> No' .1862 gAND RULER p THIS APPLICATION IS <br /> MADE IN COMPLIANCE WITH COUNTY ORDINANC►: �� <br /> OF THE SAN"JOAQUIN LOCAL HEALTH DISTRICT. <br /> REGULATIONS <br /> f.f � <br /> JOB A"USSA=ATICY. ar z <br /> OWNBR4 NAME: � � CENSUS TRACT: <br /> ADDItibs ;>� PHONE: " �X <br /> �TORS J� +Y: ,,. <br /> NAME:/ .(/ LICENSE #-�� PHONE: <br /> 1 �TB�SD�USE : '.INDIVIDUAL DOMESTIC.WATER WELL - ` <br /> � + IRRIGATION/LIVESTOCIC/AGRICUL PUBLIC WATER WBI.L �� TEST. WELL.L-J. <br /> '� ri �ATBODIC PROTECTION.WELL ' WATER WFLL /— <br /> /I GEOPHYSICAL WELL L� <br /> INDUST WATER WELL f <br /> OTHER — J <br /> ._. _. / <br /> N �i�IILr:M DISG4I�CE TO NEAREST: SEPTICTAW - " <br /> }� SEWACE`bISPOSAL" FIELD SQ SEWER LINES PIT PRIVY <br /> yi - CESSPOOL SEEPAGE PIT„ OTS' <br /> REPAUSS,p�zYPE OF REPAIRS: �f <br /> ..v;�'<t3;4•N dot? ,. _ ' r'S. <br /> ARANDQNMF.NT g •;,. k <br /> /D .STRUCTION: METHOD TO BE USED: <br /> �. " . ''�---"`•�' s ski <br /> y 1 <br /> PLCI'>PLAN: `SHOW ON PEVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE k!ORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THP ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQU AL HEALTH DISTRIC <br /> SIGNED: J . <br /> CONTRACTOR: <br /> y <br /> FOP. DEPARTMENT USE ONLY <br /> PHASE:I <br /> APPLICATION ACCEPTED BY: <br /> ADDITIONAL COi' mNTS: DATE: p u, <br /> � r <br /> . a <br /> PHASE II PHASE III FINAL . <br /> INSPECTION BY: km DATE 5-10- <br /> _ INSPECTION BY: DATE �-1 O <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRIC I/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNp ER—PINK-CONTRACTOR !� <br /> cl �cfi f <br /> t <br /> }f <br /> 1 <br />