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R OFFICE USE: APPLICATION FOR WELL OR PUMA' PERMIT PERMIT NO. 72 - 7 8 S <br /> (Complete in Triplicate) Date Issued: 7, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 <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 y <br /> NO. 1862 AND RALES AND REGULATIONS OF THE SAN <br /> JOAQUIN LOCAL HEALTH DIoSTnRI•CT.ee Ki <br /> 0 SI <br /> JOB ADDRESS/LOCATION: SC' e- CENSUS TRACT: <br /> OWNER'S NAME: y 1 1 - -- PHONE- <br /> ADDRESS: CITY: <br /> CONTRACTOR'S NAME: ; LICENSE Ti �1,;7,Zfejn PHONE: 22 7-,g <br /> La <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL PUBLIC WATER WELL / / TEST WELL <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL' WATER WELL /%_INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> (NUT , <br /> NEW WELL: DISTANCE TO ST: SEPTIC TA�QK SEWER LINES PIT PRIVY Irv , <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: }�(,C �J✓ / - , ,� - J ( ' <br /> .=\ `.-• '�-4-: .tee-.,� ..'�- --�- _ - _� � fi <br /> ABANDONMENT/DEStRUCTION METHOD TO BE USED: <br /> .f <br /> PLOT PLAN: SHOW ON REVERSE SIDE ► <br /> F <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILT, BE DONE IN <br /> ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN �OAQUIN, AND THE/RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTHDISTRICT. <br /> SIGNED: <br /> CONTRACTOR: XiiLc� 4Z�r <br /> PHASE I FOR DEPARTMENT -USE ONLY C <br /> APPLICATION ACCEPTED BY: �r <br /> i <br /> _ �` +u-a DATE: X/-27 2-� <br /> ADDITIONAL COMMENTS: <br /> PHASE II PHASE III/FINAL <br /> INSPECTION BY: DATE 7 ?� :,; INSPECTION BY: �/v, DATE <br /> E H 1426 SAN JOAQUIN LOCAL HEALTH DISTRICT 1/72 1M <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT .- YELLOW-PROPERTY OWNER - PINK-CONTRACTOR <br />