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FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. - / �/ o a <br /> '.. (Complete in Triplicate) Date Issued: 3/20/72 <br /> IS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED <br /> x, J <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 /> JOB ADDRESS/LOCATION: MILLERICK RANCH 31268 E.Combs Rd.CENSUS TRACT: <br /> OWNER'S NAME: M. E . Mi ll e ri ck_ PHONE: <br /> ADDRESS: 333Q Stockbridge Ave Lps A ele Calif. CITY: <br /> CONTRACTOR'S NAM ennin s Bros ri ng o. LICENSE # 116322 PHONE: 522-564 <br /> 2500 W. um eo esto,Ca . <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL l PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDtFS-TRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 75' SEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELA CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: rm <br /> } <br /> 4 <br /> L <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> 4 <br /> I HEREBY CERTIFY THAT-I`!&Vi"PREPARED'THIS'APPI.ICATION AND-THAT-THE-WORK-W1-LL­-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: <br /> CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-BSS: DATE: 1,�7- 72— <br /> ADDITIONAL COMMENTS: <br /> SENror.li7`� Na y,MK oR����w CO <br /> -� <br /> PHASE II PHASE III FINAL <br /> INSPECTION BY:'=, DATE 3- 17-2 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 />