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err✓" "" y <br />i ~ <br />FOR OFFICE L'SE: APDL A ION FOR WELL OR PUMP PERMIT PERMIT NO. <br />(Complete in Triplicate) Date Issued:. <br />L IS 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 INCOMPLIANCE WITH COUNTY ORDINANCE <br />NO. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQtTN LOCAL HEALTH DISTRICT. <br />3 t f a <br />JOB ADDRESS/LOCATTON'-�°` 12622'E. Haiiaey, Lane' E ` CENSUS TRACT: S q� <br />OWNER'S NAME: ueorze W. Hames PRONE: 478 4309 <br />ADDRESS: -211 E. Iris CITY: Stockton <br />CONTRACTOR'S NAME: J. A,. halhsmer Co. " LICENSE # 72 30i PHONE: 477 1956 <br />1 <br />INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL C/ 'PUBLIC WATER WELL / TEST WELL / <br />IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /J INDUSTRIAL WATER WELL <br />CATHODIC PROTECTION WELL J' � GEOP`HYSICAL WELL % / 'OTHER _I ! <br />�. ...... -.-- <br />7 <br />NEW "WELL : DISTANCE+ TO NEAREST: SEPTIC TANK 80ftSEWER LINES 80f'tfIT PRIVY <br />SEWAGE DISPOSAL FIELD80 ft -CESSPOOL SEEPAGE PIT OTHER. <br />REPAIRS: TYPE OF REPAIRS: Drill and case six inch -we'll. Owner to install his <br />owr * Pressure system <br />ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br />i <br />f <br />9 <br />PLOT PLAN: ,SHOW ON . REVERSE SIDE '"""• , '' <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS AEPLICATION AND THAT THE WORK WILL BE DONE IN <br />ACCORDANCE WITH THE .PROVISIONS OF THE LAWS OF THE STATE OF-CALIF'ORNJA,-THE-ORDINANCES OF THE <br />COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL RLkLTH DISTRICT. <br />SIGNED: <br />.....- 'CONTRACTOR: s, t <br />I. <br />FOR DEPARTMENT USE ONLY ' <br />PHASE I -- t --l_.,. _ ..,..._....•.--...,, <br />;�,_ <br />APPLICATION ACCEPTED BY: x DATE: <br />ADDITIONAL COMMENTS: <br />PHASE II• <br />INSPECTION BY: .�j� DATE e$,� INSPECTION BY: � _ ._ DATE _3"-,7.2�- <br />E H 1426 'SAN JOAQPIN LOCAL HEALTH DISTRICT 1172 34 <br />DISTRIBUTION: WHITE -HEALTH DISTRICT W YELLOW_PROpERTy OWNER -- PINK CONTRACTOR <br />