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FOR OFFICE USE: PLICATION FOR WELL OR PU`lY PF32MIT PERMIT NO. n i <br /> �Ce�mplete in Tripl fcae} Date Issued: 5 � ; <br /> TH S PERMIT EXPIRES 3 REAR FROM DATE ISSUED <br /> 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 /> N0. 1862 AND RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> q <br /> JOB ADDRESS/LOCATION: ' (i`, '�' tSTZ" :M CENSUS TRACT: 'V,,L) O'f0-2 - <br /> OWNER'S NAME: cSE PHONE: <br /> ADDRESS: 7 d Q C,9 70 CITY: <br /> CONTRACTOR°S NAME: CO LICENSE # 7LLz PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC WATER WELL Yi PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL—/—/ OTHER <br /> z <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> REPAIRS: TYPE OF REPAIRS- ik S <br /> 171 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> iii. __. ._.Y.. . S• � r-. _. + W A �� . <br /> t <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. TH DISTRICT. <br /> SIGNED:4_ , CONTRACTOR. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- . <br /> APPLICATION ACCEPTED BY: DATE: 0 7 <br /> ADDITIONAL COMMENTS: y <br /> i <br /> PHAS H _� ,_. _ P I/FINAL <br /> INSPECTIO14 BY: DATE ���/1� Y INSPECTION BY: DATE <br /> E H 1426 `' SAN JOA UIN LOCAL HEALTH DISTRI 3./72 1M <br /> DISTRIBUTION: TE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER - CTOR <br />