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FOR OFFICE USE: LIGATION FOR WELL OR PUMP PERMIT PERMIT NO. 71 - i ' j <br /> (Complete in Triplicate) Date Issued: 3-/ 7 2- <br /> '11:1 THIS 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 /> 3_1JOS ADDRESS/LOC TION: !IAO �iJ w ! cr ` CENSUS TRACT: i <br /> OWNER'S NAME: '' ► P HONE: (6 <br /> ADDRESS: - AD/L CITY: <br /> CONTRACTOR'S NAME: LICENSE #&1373 PHONE: (� — <br /> INTENDED USE: INDIVIDfTAT DOMESTIC. WATER WELL / / PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL ANIINDU�S_TRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / f GEOPHYSICAL WELL / / OTHER I / <br /> NEW WELL: DISTANCE TONEARESTx: SEPTIC TANK SEWER LINES k / PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT: " " ''.OTHER NI <br /> REPAIRS: TYPE OF REPAIRS., 4�.I��/-fV\ _ �S � � u � �l'j� P <br /> Z- <br /> 16 <br /> • it j, �` <br /> k—ABANDONMENT/DESTRUCTION: -- METHOD-TO BE USED:—�� <br /> i' <br /> 0 <br /> I <br /> i 9 <br /> PLOT PLAN: SHOW ON REVERSE SIDE, f <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THEIWORK 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 /> .�I hh4 <br /> SIGNED: CONTRACTOR: AJ ' � _ <br /> ` II <br /> Ilk <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> _ r <br /> APPLICATION ACCEPTED BY DATE: � � <br /> ADDITIONAL COMMENTS: 11. <br /> PHASE III PH4fSE III FINAL <br /> INSPECTION BY: DATE INSPECTION BY: DATE <br /> E H 1426 'I�i '� SAN JOAQUIN`LOCAL HEALTH DISTRICT 1/72 IM. <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW--PROPERTY OWNER - PINK-CONTRACTOR <br />