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p1111y1 f1*6 PRAM/T <br /> FOR OFFICE USE: �,kiPPLICATION FOR WELL 0R PUMP PERMIT PERMIT NO. . 77�-ia <br /> - eV (Complete in Triplicate) Date Issued: -3 yf ! <br /> THIS PERMIT EXPIRES I 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. <br /> ,BSL--�4llt n'og/LE_,ESTi4-�ES , <br /> JOB ADDRESS/LOCATION: ,S S 3.S CENSUS TRACT: <br /> OWNER'S NAME: e 59L--47,01y ----- -- PHONE: o U <br /> ADDRESS: _Tg,?g �%i�i?dk �, . S� �[� SD2cR7 & -CITY: <br /> CONTRACTOR'S NAME: 42.E <br /> 7LICENSE # jPHONE: <br /> a-o� _ <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATE� WELL / / PUBLIC WATER WELL TEST WELL f / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL /—/ GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 360"SEWER LINES Xo' PIT PRIVY .t-" ;! <br /> SEWAGE DISPOSAL FIELD 36S-'CESSPO0L SEEPAGE PIT v OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> LP <br /> E <br /> tho i <br /> W <br /> t a <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> E <br /> PLOT PLAN: SHOW ON� YERSE 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 J�AQUfN AND T E RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. # <br /> SIGNED: / CONTRACTOR: U G <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: . <br /> j' PHASE I P II&FINAL <br /> INSPECTION BFEHWWALTH <br /> DATE �� Y INSPECTION B DATE <br /> E H 1426 ''SAN -JOAQUIN LOCAL HEALTH DIST 1/72 1M <br /> DISTRIBUT DISTRICT -- YELLOW-PROPERTY OWNER1PINK-CONTRACTOR <br />