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r._�,,.------.mss•-,..,-r-,- — � �y�. <br /> FOR OFFICE USE: APPLICATION FOR WELL OR PUMP PERMIT PERMIT N0. <br /> (Complete in Triplicate) Date Issued: 3. 2-P.- 77-- <br /> THIS <br /> z -77iTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1. <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/LOCATION:-' j&t, CENSUS TRACT: <br /> OW'NER'S NAME: PHONE: Se <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: ' �' tl c;• LICENSE # .37 _ PHONE: <br /> INTENDED USE:_ INDIVIDUAL :DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL /7 <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL I I OTHER I I <br /> NEW WELL: DISTANCETQ NEAREST: SEP t SEWER LIN T PRIVY <br /> SEWAGE DISPOS1Ia—F-IELD CESSPO E_PIT OTHER <br /> r <br /> REPAIRS: TYPE OF REPAIRS: <br /> h <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> s <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: ,mac uta CONTRACTOR: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY: _ _ DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASp�E. IIIFINAL <br /> INSPECTION BY: N DATE _ INSPECTION BY: DATE 5-3_q a- <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE—HEALTH DISTRICT — YELLOW—PROPERTY OWNER — PINK—CONTRACTOR C <br />