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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT 40 PERMIT NO. �L-3SL -c (Complete in Triplicate) Date Issued: HIS'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '7 y7 e APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT -TO PERFORM THE WORK STATED HEREON. THIS APPLICATION IS MADE. IN COMPF.IANCE WITH COUNTY ORDINANCE NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. of Watters JOB ADDRESS/LOCATION: 1200 ft. E. of Mc Kinlen-on N. side o:CEWsArWMRACT: [ ct3-2,9b OWNER'S NAME: Wade Loveda PHONE: 464 779 ADDRESS: 21 E. Main 5t. CITY: Stockton CONTRACTOR'S NAME: J. A. Thalhamer Co* LICENSE 4272 303 PHONE: 477 INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL */ PUBLIC WATER WELL / / TEST WELL IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / T. INDUSTRIAL WATER WELL CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER /_7 NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 60ft.SEWER LINES 70 ftPIT PRIVY SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' REPAIRS: TYPE OF REPAIRS: Drill and case six inch well. App. 120 ft. of casing J and 135 ft. of drilling ABANDONMENT/DESTRUCTION: METHOD TO BE USED: V` PLOT PLAN: SHOW ON REVERSE SIDE I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. SIGNED: ..' e O-A _ CONTRACTOR: PHASE I FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY: % -LL�. ..(f DATE: 2— ADDITIONAL COMMENTS: PHASE II tPHASE II FINAL INSPECTION BY:��e2�__ DATE _ INSPECTION BY: DATE E H 1426 SAN JQAQUIN LOCAL HEALTH DISTRICT 1/72 DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - Pi CONTRACTOR /3l,