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FOR OFFICE U5 : APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. <br /> 1 (Complete in Triplicate) Date Issued: 3_--v1 _-7 <br /> THI 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, f,. Ld f ; <br /> JOB ADDRESS/LOCATION: 12 -7-76 - CENSUS TRACT: 2)'o CasflP Trra f <br /> OWNER'S NAME: �r <br /> PHONE: 823-533 <br /> ADDRESS: 76 S. -e CITY: cr•1 e c <br /> CONTRACTOR'S NAME: LICENSE #li162_3 PHONE: <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /�T _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL %/ OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 70 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> N ' <br /> REPAIRS: TYPE OF REPAIRS: <br /> 6` <br /> V1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATEkOF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> E SIGNED: CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY: T- DATE: <br /> ADDITIONAL,COMMENTS: . <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE S-2&9 INSPECTION BY: - DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br /> 1 <br />