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f <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. :.77-- Z33 ' <br /> (Complete in Triplicate) Date Issued: --7�7 v c <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 /> a <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/LOCAT N: S �' y ` - rC CENSUS TRACT: <br /> OWNER'S NAME: PHONE: 3 fvyam&/ EX <br /> ADDRESS: ' CITY: <br /> CONTRACTOR'S NAME: - ,Q LICENSE # 6 2.323 PHONE: F'= 3_r, <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL / / TEST WELL /7 _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL Pq_INDUSTRIAL WATER WELL L-1 <br /> r. CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK `'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' I <br /> i <br /> i <br /> REPAIRS: TYPE OF REPAIRS: <br />—ABANDONMENT/DESTRUCTION: -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 I <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 OF4THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> SIGNED: CONTRACTOR: <br /> 1 <br /> FOR DEPARTMENT USE ONLY { <br /> PHASE I <br /> APPLICATION ACCEPTED BY: ----. . r DATE: ` <br /> ADDITIONAL COMMENTS: <br /> 4 <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE ,//-,2-4— <br /> - - i <br /> E H 1426 - <br /> SAN-JOAQUIN I,OCAI, HEALTH DT_ST-AICT, If72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />