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FOR OFFICE USE: APPLICATION FOR WELL OR PUMA' PFRMIT <br /> _ PERMIT N0. <br /> (Complete in Triplicate) Date IBsued: <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> i <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM I <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: 1 4 4 R E <br /> OWNER'S NAME: c CENSUS TRACT: ' <br /> ADDRESS: B PHONE': <br /> CONTRACTOR'S NAME: � I v N �. CITY:� <br /> c .ICENSE 4i Z 76 i PHONE: <br /> s <br /> INTENDED USE: INDIVIDUAL.DOMESTIC WATER WELL l PUBLIC WATER WELL /_l TEST WELL /_ _ <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / / INDUSTRIAL WATER WELL <br /> CATHODIC PROTECTION WELL / / GEOPHYSICAL WELL / / OTHER <br /> NEW WELL: DISTANCE TO NEAREST: SEPTIC TANK A/vAMEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ' <br /> REPAIRS:-"'"TYPE OF REPAIRS <br /> m , <br /> ' � t <br /> s <br /> ABANDONMENT/DESTRUCTION: METHOD TO BE USED.- <br /> PLOT <br /> SED.PLOT PLAN: SHOWYON REVERSE SIDE M1 <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: <br /> CONTRACTOR: f-6 A/I t1�'/ S A L ' <br /> E � J`9 Sue., pc e� <br /> FOR DEPARTMENT USE ONLY <br />'RASE I } <br />,PPLICATION ACCEPTED BY: <br /> ADDITIONAL COMMENTS: DATE: <br /> r PHASE I <br /> PHASE III FINAL <br /> NSPECTION BY: DATE INSPECTION BY / l� <br /> H 1426 . : DATE .-7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _' ' 1/72 1M <br /> ISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER _ PINK-CONTRACTOR i <br />