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1 Yl i <br /> FOR <br /> OFFICE USE:- ' ',�ATION FOR' <br /> WELL OR PUMP PERMIT PERMIT NO. 7 Z- Z -7 3 <br /> (Complete in Triplicate) Date Issued: �Wv <br /> 1HIS PERMIT EXPIRES _1 YEAR FROM DATE ISSUED <br /> APPLICATION IS HEREBY MADE TO .THE SANJOAQUIN LOCAL HEALTH DISTRICT FORA 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 ;`JOAQU N LO AL HEALTH DISTRICT. <br /> JOB ADDRESS/LOCATION: -+ ' `�1 '- �- -g- . CENSUS TRACT: <br /> OWNER'S NAME: ze3 c %L.4a w,z �] PHONE: <br /> ADDRESS: 0, a Q , ....._ n: .r CITY: <br /> CONTRACTOR'S NAME: - 'r+' '' ' �: cj , . " ""'_`� LICENSE I aG,3 PHONE: 741' I .3 Y'7 <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 /> i <br /> ,e <br /> g--. <br /> "NEW"WELL: DI STANCE£TO-NEAREST: SEPTIC"TANK I�'( SEWER' LINE5 1 5" d PIT'PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER <br /> REPAIRS: TYPE OF REPAIRS: <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED: <br /> h <br /> ip l� <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: CONTRACTOR: <br /> iI FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY: I � DATE: / <br /> I ADDITIONAL COMMENTS: <br /> f <br /> PHASE II I FINAL <br /> INSPECTION. BY: , DATE : �{��d�-72 INSPECTION BY: DATE <br /> E H 1+26 '�"�` SAN`JOA UIN`LOCAL HEALTH DISTR 1/72 IM <br /> DISTRIBUTION: WHITE-HEALTH DISTRICT -- YELLOW-PROPERTY OWNER NK-CONTRACTOR <br /> II ' <br />