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FOR OFFICE USE: (�p=FOR WELL OR PUMP PERMIT PERMIT NO'I. ' z �5 <br /> II (Complete in Triplicate) Date Issued: 3- - � - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM t <br /> THE WORK STATED HEREON. I1 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: CENSUS PHONE: <br /> OWNER S NAME: tI_ /Z2 7_ <br /> ADDRESS: CITY: <br /> LICENSE # PHONE: <br /> CONTRACTOR'S AME: l�/e r- ��� _ <br /> .r <br /> INTENDED USE: INDIVIDUAL_-DOMESTIC WALL PUBLIC WATER WELL / / TEST WELL /-7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> cATHODICIPROTECTION WELL / / GEOPHYSICAL WELL / / OTHER /_7 i <br /> I <br /> NEW WELL: DISTANCE TO ST: SEPTIC T LINES PIT <br /> SEWAGE DISPOSAL FIEL CESSPOOL +SEEPAGE PIT OTHER <br /> ii II <br /> REPAIRS: TYPE OF REPAIRS: <br /> W <br /> - !I <br /> ABANDONMENT/DESTRUCT Nc METHOD TO BE USED: <br /> u - I <br /> i' <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> II <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 /> l <br /> SIGNED: CONTRACTOR: <br /> H !M <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY;: DATE: <br /> ADDITIONAL COMMENTS: ii 0 <br /> PHASE II P I FINAL. <br /> � I <br /> r INSPECTION BY: I' DATE INSPECTION BY• 7y— DATE `= 7 <br /> E H 1426 ! SAN JOA UIN LOCAL HEALTH DISTR 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -CONTRACTOR <br />