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FOR,,OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> :. <br /> . (Complete' in:-Triplicate). Date Issued: _�_ Z G-7 t- <br /> - HIS PERMIT EXPIRES I` YEAR-PROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM ,` <br /> THE WORK- STATED HEREAFTER. THIS APPLICATION' IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO.­1862 AND RULES AND REGULATIONS. ' i <br /> ' a 3 - CENSUS TRACT: <br /> JOB ADDRESS/LOCATION. Lot 11 Cal Dry � -__--- s <br /> OWNER'S NAME: .B PHONE: - <br /> 3FA_777� <br /> ADDRESS': _ 2224 _Jgrlcsnn 5+-j, .I:Qd;. Calike � - <br /> _ CITY: <br /> CONTRACTOR'S NAME: Gin. JonQuin B= Coe.,Inc* LICENSE. # 17205 _ PHONE; �89�R477 <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL -/ / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES PIT PRIVY SEWAGE <br /> DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDON/DESTRUCTION METHOD TO. BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE ', <br /> I HEREBY CER3IFY THAT I -HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE IT AN ;TOAQUIN C TY ORDINANCES, STATE. LAWS,AND RULES_AND,,,REGULAT.IONS,,. THE— <br /> SAN JOAQU N LHEAL H STR <br /> SIGNED: :. CONTRACTOR: San Jo , in Pum GERany, Inc. <br /> FOR DEP AR NT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY: DATE; / a 7Z7; . <br /> ADDITIONAL COMMENTS•0 -- - - ---- __-- <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY DATE DATE', <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> E0 11y <br /> A j <br />