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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO.'3 <br /> (Complete in Triplicate) Date Issued: J1- <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 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 /> K"U/y' ,t}- - mile N. of Frontage 99 <br /> JOB ADDRESS/LOCATION'- On West side of barren Ave. about 1/4/ CENSUS TRACT: 5 S�7 <br /> OWNER'S NAME: - N1CK SCHOLTM-- -- -- -- - - �T PHONE: 599-404 <br /> ADDRESS: 22785 S. 'barren Ave., `. <br /> CITY: Ripon, Calif CONTRACTOR'S NAME: X & S Hot.'E -ME- ,IAN{S CO.^ LICENSE # 99612 PHONE: 599-3456 USE: INDIVIDUAL..DOMESTIC WATER WELL _ PUBLIC WATER WELL / / TEST WELL /_1 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /-7/- INDU—STRIAL WATER WELL f_1 <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 5V SEWER LINES I PIT PRIVY 1V19AfV7 <br /> SEWAGE DISPOSAL FIELD �---C-ESSPOOL SEEPAGE PITAfO- OTHER fV0 n(f <br /> REPAIRS: TYPE OF REPAIRS: Move pump from one location to_anotherincluding.�tank and fittings. <br /> • 4 w <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br />_I_HEREBY.ICERTIFY_.THAT. I-HAVE PREEARED THISYAP-RLICATION-AND£THAT-THE-WORK-WILL 4SE-DONE•»IN = --- <br /> ACCORDANCE WITH THE -PROVISIONS OF�_THR LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE-RULES AND REGULATIONS OF THE SAN JOAQUIN :W= HEAL ISTRICT <br /> SIGNED: CONTRACTOR: <br /> N Rt ,$� HOn+H; ,apPZ2ANCF d0• <br /> OR DEPARTMENT USE ONLY <br /> PHASE I � , <br /> APPLICATION ACCEPTED DATE: /Zzz <br /> ADDITIONAL CO T <br /> 41 <br /> AAA�_- <br /> PHASE .II FINAL_ _ <br /> INSPECTI013 IY: -. __ _ . .- -9- DATE-/����' " -INSPECTION"' BY: DATE <br /> E H 1426=' SAN JOA UIN LOCAL HEALTH DISTRICT 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />