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PERMIT NO. Z-r U-1 �' <br /> FOR OFF7E USE: APPLICATION FOR WELL OR PUMP PERMIT r <br /> / (Complete in Triplicate) Date issued: -1Lz <br /> THI PERMIT EXPIRES I YEAR FROM DATE. ISSUED <br /> APPLICATION <br /> IS HEREBY MADE TO SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM # <br /> THE WORK STATED HEREON: THIS A PLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REGULATIONS OF TH SAN JOAQUIN L CAL;,7 TH DTSTR �)+s0-_ 1`fes <br /> CENSUS TRACT: _ k <br /> `30B ADDRESS/LOCATION: PHONE: 3 r 4 <br /> OWNER'S NAME: CITY: <br /> ADDRESS: ' LICEN � 'PHONE: 99 <br /> I CONTRACTOR'S NAME•6 _ <br /> �8� y <br /> INTENDED USE: INDIVIDUAL-DOMESTIC ATER WELL PUBLIC WATER WELL TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL <br /> WATER WELL INDUSTRIAL WATER WELL I / <br /> `GATHODIC 'PROTECTION WELL J GEOPHYSICAL WELL / / OTHER L/ <br /> NEW WELL• DISTANCE TONEAR_EST-: ; _SEPTIC_.TANK --=±- - SEWER=:LINES : PIT'PRIVY- - — �— <br /> " StWaGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' 09 <br /> Ch <br /> REPAIRS: TYPE OF REPAIRS: Q <br /> e <br /> C <br /> ' s <br /> ABANDONMENT/DESTRUCTION: METHOD TO"BE USED: <br /> 1 <br /> I 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 /> } _ <br /> ACCORDANCE-WITHTHE PROVSION5.OF THE LAWSiOF THE STATE�OF_CALTFORNTA, THE ORDINANCES OF _ <br /> t COUNTY OF SAN JOAQUIN, AND Tiff:kULES AND REGULATIONS OF'THE'SAN JOAQUIN LOCAL HEALTH DIST1,1 <br /> ICT.; <br /> CONTRACTOR: <br /> SIGNED: <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> _ __ : -�` <br /> f APPLICATION ACCEPTED BY: � <br /> � <br /> DATE2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> f <br /> INSPECTION BY: , DATE <br /> INSPECTION BY DATE Z~s� <br /> E H 1426 SAN JOA UIN LOCAL HEALTH DISTRICT I/72 ] <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER -• PINK-CONTRACTOR W <br />