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FOROFFIC-E USE: APPLICATION F R WELL OR PUMP PERMIT PERMIT NO. -5 .3 <br /> (Complete in Triplicate) Date Issued: ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7� 7- y <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 /> 6803 Coy; Road <br /> JOB ADDRESS/LOCATION: 3L4 Mdie S. Comstock e 601 _",{. Cox CENSUS TRACT• <br /> +OWNER'S NAME: Frank Giannecch-]n:; <br /> - PHONE: 687-3963 <br /> ADDRESS: -15400''E' Hwy 26 , xind. en Calif. 9 4t CITY: LinaEn <br /> CONTRACTOR'S NAME: Purviance Dril le s LICENSE #240107 PHONE: 931-44 <br /> 66 <br /> INTENDED USE: INDIVIDUAL-:DOMES•TIC WATER WELL ,fs / PUBLIC WATER WELL / / TEST WELL /- <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER <br /> A <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK 100: SEWER LINES 1001 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PITS OTHER <br /> 7 <br /> REPAIRS: TYPE OF REPAIRS: ;. <br /> _ <br /> e <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 /> f ACCORDANCE WITH THE PROVISIONS OF THE'aWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> I COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOC L HEALTH DISTRICT. <br /> 7D A 5'Z- <br /> E SIGNED: X F CONTRACTOR: Furviance Drillers <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. 0 . <br /> ADDITIONAL COMMENTS: DATE: <br /> PHA EI <br /> I FINAL <br /> INSPECTION BY: DATE - INSPECTION BY DATE S -7 <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRI 1/72 1M <br /> DISTRIBUTIO WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER _CONTRACTOR <br />