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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. 72---17 y E <br /> (Complete in Triplicate) Date Issued: --z a-7 Z <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 j <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 /> JOB ADDRESS/LOCATION: 4907 Cherokee Lane CENSUS TRACT: <br /> OWNER'S NAME: ermes! Young- PHONE <br /> : 478 4932 <br /> ADDRESS: 1549 Douglas Rd. CITY: Stockton <br /> CONTRACTOR'S' NAME: Jae Machado Cos- LICENSE 4255977 PHONE: 463 30O <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL PUBLIC WATER WELL /-/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / WELL f_1 <br /> INDUSTRIAL WATER WE /_/ <br /> CATHODIC PROTECTION WELL/ / GEOPHYSICAL WELL / / OTHER / / <br /> i <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK $I f'tSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: Fill sig 5.narh well- and put in pump � • � <br /> , v <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: � n <br /> o <br /> a � + <br /> /lp S <br /> S' <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 STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: �., Ga.-�i,.. CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br />' ADDITIONAL COMMENTS: <br /> , c <br /> � iv PHASE II 'PHASE III FINAL11 <br /> 'ISPECTTON BY;.- DATE T INSPECTION BY: uDATE� y <br /> F H 1426SAN JOAQUIN LOCAL HEALTH DISTRICT 1f72 1M � <br /> f <br /> 7RIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PlkfK-CONTRACTOR <br />