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- t <br /> FOR OFFICE USE: UAPPLICATION7 FOR W L OR--IMP PERMIT PERMIT NO. L-Z y'7 <br /> (Complete in Triplicate) Date Issued: <br /> HIS PERMIT EXPIRES 1 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 /> .JOB ADDRESS/LOCATIO :, ENSUS TRACT: "A)r 0�-[&0-27 <br /> DOWNER'S NAME PHONE: <br /> ADDRESS: A CITY: <br /> CONTRACTOR'S NAME: LltENSE # PHONE: 4y d rz Ea <br /> INTENDED USE: I VIDUAL DOMESTIC WATER WELL / / PUBLIC WATER WELL /—/ TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /Vr INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK t. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER' <br /> .REPAIRS: TYPE OF REPAIRS: rv 0 <br /> ABANDONMENT/DESTRUCTION: METHOD TO 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 <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: �� CONTRACTOR: 44� <br /> f <br /> OR DEPARTMENT USE ONLY <br /> PHASE I Y <br /> APPLICATION ACCEPTED BY: DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II E II; FINAL <br /> INSPECTION BY: DATE INSPECTIONBY: ' DATE ^y� E-7-2- _ <br /> E H 1426 "_ . SAN JOA UIN LOCAL HEALTH DISTR T{. -,�' 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER fIPINK- ONTRACTOR <br />