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FOR OFFICE USE: <br /> APPLICATION FOR WELL OR PUMP PERMIT PERMIT NO. Z 3 <br /> (Complete in Triplicate) Date Issued: c 7 <br /> T S 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/LOC ION: p 7 p CENSUS TRACT: <br /> -OWNER'S NAME: V �✓ ` PHONE: <br /> ADDRESS: f 6, G CITY: V <br /> CONTRACTOR'S NAME:.. 17�5rql/jsae, _ LICENSE # 1goT-3-2 PHONE: <br /> INTENDED USE: INDIVIDUAL DOMESTIC -WATER WELL /17 <br /> --"PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL /—/ IND STRIAL WATER WELL <br /> ATHODICeJOXECTION,`,�QI�r/ / GEOPHYSICAL WELL / / OTHER <br /> SS oo. , l lam '/ 6 <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK j' b SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: ` <br /> k <br /> ryy <br /> ' f S <br /> F . <br /> x <br /> 1 <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: A ° <br /> a � <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 JOAQUIOC TH DISTRICT. <br /> SIGNED: CONTRACTOR: &10 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> M <br /> APPLICATION ACCEPTED BY: DATE: T 72, <br /> 1 <br /> ADDITIONAL COMMENTS; <br /> MP I FINAINSPECTION BL <br /> DATE , � �j INSPECTION BY: DATE _ � �v <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRIC 1 - <br /> DISTRIBUTIO H DISTRICT - YELLOW-PROPERTY OWNER - -CONTRACTOR <br />